HospitalInspections.org

34337

34337



34338

34337

Based on record review and staff interviews, the facility failed to include individual patient problems in the master treatment plans (MTP) for three (3) out of six (6) active sample patients (2, 3 and 5). Specifically the facility failed to include the problem of suicide in the problem list of the master treatment plans for these patients. This failure results in the poor treatment, not meeting the needs of the patient and delayed discharge.

Findings include:

A. Record Review

1. The MTP dated 5/18/15 for Patient 2, a 24 year old male admitted on 5/14/15 for suicidal attempt after stabbing himself in the abdomen needing exploratory laparotomy included in the problem list "(Pt.) states he does not feel he is worth anything. Identifies: poor self-esteem, eating disorder, depression, multiple stressors." It did not include this serious suicidal attempt in the problem list.

2.The MTP dated 5/18/15 for Patient 3, a 15 year old female admitted on 5/15/15 after threatening suicide after the death of her 20 years old friend included following problems in the problem list "depression-major, ongoing family conflicts and situational grief related to death of a friend." It did not include the threat of suicide.

3.The MTP dated 5/11/15 for Patient 5, a 27 year old male admitted on 5/8/15 after a suicidal attempt by cutting his forearm included following problems in the problem list "misuse of ETOH, dependence, ETOH withdrawal, 'My anxiety' and depression." It did not include the suicidal attempt.

B. Staff Interview

1. During interview with review of treatment plans for Patient #s 3 and 5 on 5/19/15 at 10:00 a.m., the Director of Social Work stated "We need to look at the core reason (suicide) for admission, not just the symptoms."

2. In an interview with the Medical Director on 5/19/15 at 1:15 p.m., the Clinical Director agreed with the surveyors that the suicide problem was not listed in the MTPs of the active sample Patients 2, 3 and 5. He added "Suicide should have been clearly stated in the plan with goals and interventions."

Based on record review and staff interviews, the facility failed to develop Master Treatment Plans (MTP) that included appropriate short term goals for two (2) of six (6) active sample patients (2 and 6). The MTP goals for these patients were non-measurable and lacked timeframe for goal achievement. The facility also failed to list long term goals for three (3) of six (6) active sample patients (1, 3 and 5). Failure to develop and list appropriate short term and long term goals on MTPs compromises staff ' s ability to provide goal directed care and measure patients' responses to treatment, potential resulting in prolonged hospitalization.

Findings include:

A. Record Review

1. Patient 1 admitted on 4/24/15 with date of MTP 5/8/15 had no long term goals listed.

2. Patient 2 admitted on 5/14/15 with date of MTP 5/18/15 had following short term goals listed. "(Name of Patient) will identify supportive measures he can take to remain safe in the community." "(Name of Patient) will work with staff to develop safety plan and follow up care interventions and contacts for out-patient services by discharge." These goals are non-measurable and lack time frame for goal achievement.

3. Patient 3 admitted on 5/15/15 with date of MTP 5/18/15 had no long term goals listed.

4. Patient 5 admitted on 5/8/15 with date of MTP 5/11/15 had following listed as long term goals. "Be a better father", "Control rage issues" and "Quit Drinking."

5. Patient 6 admitted on 5/14/15 with date of MTP 5/16/15 had one of the short term goals listed "(Name of Patient) will understand medication compliance and management by discharge." This goal is non-measurable and lacks time frame for goal achievement. No long term goals were listed.

B. Staff Interview

1. In an interview with RN1 and RN5 on 5/19/15 at 10:00 a.m. RN1 acknowledged that the long term goals were missing and short term goals were not measurable.

2. During discussion with review of treatment plan for Patient #5 on 5/19/15 at 1:15 p.m., the Clinical Director, primary physician for the patient, stated, "Suicide should have been clearly stated in the plan with goals and interventions."

Based on record review and staff interviews, the facility failed to develop patient specific, individualized and focused treatment interventions in the Master Treatment Plan (MTP) of four (4) of six (6) active sample patients (2, 3, 5 and 6). This failure results in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed.

Findings include:

A. Record Review

1. Patient 2 was admitted on 5/14/15 for suicidal attempt after stabbing himself in the abdomen needing surgical intervention. MTP dated 5/18/15 did not list specific and focused nursing interventions for this serious suicidal attempt.

2. Patient 3, a 15 year old female admitted on 5/15/15 after threatening suicide after the death of her 20 year old friend. The MTP dated 5/18/15 failed to include nursing interventions for safety related to threat of suicide.

3. Patient 5, a 27 year old male was admitted on 5/8/15 after a suicidal attempt by cutting his forearm. The MTP dated 5/11/15 failed to include nursing interventions for safety related to threat of suicide.

4. Patient 6 was admitted on 5/14/15 for being suicidal after breakup with girlfriend. MTP developed on 5/16/15 listed "suicidal" and "conflict/breakup with girlfriend" as problem list. There were no specific nursing focused interventions for safety related to suicide problem in the MTP.

B. Staff Interviews

1. During interview with review of treatment plans for Patients' 3 and 5 on 5/19/15 at 10:00 a.m., RN1 stated, "Nursing needs to tie into the problem list and the plan." This statement was after discussion about failure to ensure preventive nursing interventions for problem, suicide.

2. During discussion with review of treatment plan for Patient 5 on 5/19/15 at 1:15 p.m., the Clinical Director, primary physician for the patient, stated, "Suicide should have been clearly stated in the plan with goals and interventions." For this patient, the Clinical Director stated that the patient's "treatment (plan) should have correlated the alcohol drinking to his/her long-standing depression and anxiety."





30490

25355

Based on record review and staff interviews, the facility failed to identify the responsible team member by name for the treatment interventions recorded on the Master Treatment Plans (MTP) for five (5) of six (6) active sample patients (1, 2, 3, 5 and 6). Master Treatment Plans for these patients listed the discipline as responsible for interventions instead of individual staff member by name and discipline responsible for the interventions. This failure results in the facility's inability to monitor staff accountability for specific treatment interventions.

Findings include:

A. Record Review

1. MTP dated 5/8/15 for sample Patient 1 admitted on 4/24/15 did not include specific staff member by name responsible for all of the interventions listed.

2. MTP dated 5/18/15 for sample Patient 2 admitted on 5/14/15 did not include specific staff members by name responsible for all of the interventions listed.

3. MTP dated 5/18/15 for sample Patient 3 admitted on 5/15/15 did not include specific staff members by name responsible for the intervention "Offer support and discussion as tolerated for grief process related to acute stressor of friend's death-nursing."

4. MTP dated 5/11/15 for sample Patient 5 admitted on 5/8/15 did not include specific staff member by name responsible for the interventions. It listed nursing discipline, "psych" discipline and OT discipline for the interventions.

5.MTP dated 5/16/15 for sample Patient 6 admitted on 5/14/15 did not include specific staff member by name responsible for the following interventions "Medication review and education regarding medication use-nursing. Medication management and adjustment of lithium-MD, work on relationship conflicts resolution or acceptance-psych/nursing."

B. Staff Interview

1. In an interview by the surveyors with RN1 and RN5 on 5/19/15 at 10:00 a.m. RN1 acknowledged that MTPs lacked specific staff member by name responsible for the interventions.

2. During interview with review of treatment plans on 5/19/15 at 10:00 a.m., the Director of Social Work stated "We need to address specific person who is responsible for interventions."

3. During discussion with review of treatment plans on 5/19/15 at 1:15 p.m., the Clinical Director verified that staff responsible for listed interventions were not named in the treatment plans.

Based on observation, interview and document review, the facility failed to:

I. Ensure the presence of a Registered Nurse (RN) at all times on each shift of duty on the acute psychiatric unit. This results in failure to provide on-going professional patient assessments and the supervision and direction of non-professional nursing personnel. (Refer to B149)

II. Provide sufficient numbers of nursing personnel on the acute psychiatric unit based on the numbers and acuity needs of patients on all three shifts of duty (day, evening and night). These staffing patterns result in a lack of nursing personnel to provide on-going patient monitoring and preventive interventions and in potential safety risks for patients and staff. (Refer to B150)

III. In addition, there was failure to ensure that the Medical Director and the Director of Nursing monitored active treatment and took corrective actions. Specifically,

A. The Medical Director failed to:

1. Ensure that the Master Treatment Plans included the problems presented by the patient in the problem list. (Refer to B144, Section A)

2. Ensure that the Master Treatment Plans (MTP) included individualized short term goals that were measurable and had a time frame for the goal achievement. He furthered failed to ensure that the Master Treatment Plans listed long term goals for the patients (Refer to B144, Section B).

3. Ensure that the Master Treatment Plan included patient specific, individualized and focused treatment interventions (Refer B144, Section C).

4. Ensure that the Master Treatment Plan identified the responsible team member by name for the treatment interventions (Refer B144, Section D)


B. The Director of Nursing failed to:

I. Ensure that treatment plans included individualized nursing interventions for four (4) of five (5) active sample patients (2, 3, 5 and 6) presenting with potential for suicide. This failure prevented nursing personnel from providing safe, consistent focused treatment.
(Refer to B148, Part I)

25355

Based on record review and staff interview, the Clinical Director failed to monitor and evaluate the quality of treatment of treatment and patient care. Specifically, the Clinical Director failed to:

A. Ensure that the Master Treatment Plans included the problems presented by the patient in the problem list. (Refer to B119)

B. Ensure that the Master Treatment Plans (MTP) included individualized short term goals that were measurable and had a time frame for the goal achievement. He furthered failed to ensure that the Master Treatment Plans listed long term goals for the patients. (Refer to B121)

C. Ensure that the Master Treatment Plan included patient specific, individualized and focused treatment interventions. (Refer B123)

D. Ensure that the Master Treatment Plan identified the responsible team member by name for the treatment interventions. (Refer B123)

Based on observation, interview, and record review, it was determined that the Director of Nursing failed to monitor and take corrective action to:

I. Ensure that treatment plans included individualized nursing interventions for four (4) of five (5) active sample patients (2, 3, 5 and 6) presenting with potential for suicide. This failure prevented nursing personnel from providing safe, consistent focused treatment.

Findings include:

A. Record Review

1. Patient 2 was admitted on 5/14/15 for suicidal attempt after stabbing himself in the abdomen needing surgical intervention. MTP dated 5/18/15 did not list specific and focused nursing interventions for this serious suicidal attempt.

2. Patient 3, a 15 year old female admitted on 5/15/15 after threatening suicide after the death of her 20 years old friend. The MTP dated 5/18/15 failed to include nursing interventions for safety related to threat of suicide.

3. Patient 5, a 27 year old male was admitted on 5/8/15 after a suicidal attempt by cutting his forearm. The MTP dated 5/11/15 failed to include nursing interventions for safety related to threat of suicide.

4. Patient 6 was admitted on 5/14/15 for being suicidal after breakup with girlfriend. MTP developed on 5/16/15 listed "suicidal" and "conflict/breakup with girlfriend" as problem list. There were no specific nursing interventions for safety related to suicide problem in the MTP.

B. Staff Interview

During interview with review of treatment plans for Patients' 3 and 5 on 5/19/15 at 10:00 a.m., RN1 stated, "Nursing needs to tie into the problem list and the plan." This statement was after discussion about failure to ensure preventive nursing interventions for problem, suicide.

II. Ensure presence of a Registered Nurse (RN) at all times on each shift of duty on the acute psychiatric unit. This results in failure to provide on-going professional patient assessments and the supervision and direction of non-professional nursing personnel. (Refer to B149)
Provide sufficient numbers of nursing personnel on the acute psychiatric unit based on the numbers and acuity needs of patients, especially on the evening and night shifts of duty. These staffing patterns result in a lack of nursing personnel to provide on-going patient monitoring and preventive interventions and in potential safety risks for patients and staff. (Refer to B150)





30490

Based on interview and document review the Director of Nursing failed to ensure presence of a Registered Nurse (RN) at all times on each shift of duty on the acute psychiatric unit. This results in failure to provide on-going professional patient assessments and the supervision and direction of non-professional nursing personnel.

Findings include:

A. Interviews:

1. During interview on 5/18/15 at 11:40 a.m. when asked about staffing on the night shift of duty, Mental Health Technician (MHT) reported, "There are usually three (3) technicians and 1 RN on duty. The RN may leave the ward to get food to bring back to ward, go to medical records to obtain a record and go to another unit (non distinct part) to help in a crisis."

2. During interview on 5/18/15 about 1:00 p.m., the DON reported that the RN assigned to the acute psychiatric unit may leave the ward to a) get meal at the cafeteria to take back to the unit, b) go to medical records to obtain a chart after usual working hours when medical records is closed, and to take a crash card and AED to another unit (non-distinct part). She stated the maximum time is 4-5 minutes.

3.During interview on 5/19/15 at 10:00 a.m. with RN1 and RN5, RN1 reported that the RN assigned to the Acute Psychiatric Unit would leave the ward to answer an emergency (code) on another ward (non-distinct part) taking the crash cart and may go to the vending machine and bring food back to the ward. She added that the RN is usually able to return to the ward within 5-10 minutes, but "if the RN needs to remain with the patient and wait for the EMT to come, it could take longer." RN 5 stated "When I work the 6:30 to 3:00 (day) shift, if I left the ward, I may have to get a record (sic)." RN1 stated "I understand the concern for patients (referring to the staffing discussion about monitoring)."

B. Review of the staffing schedule provided by the DON for the Acute Psychiatric Unit for 5/12/15 through 5/18/15 (first day of the survey) revealed only one (1) RN on duty on the day shift on 5/14/15, 5/15/15, 5/16/15, 5/17/15 and 518/15 with the exception of one (1) additional RN from 10:00 am to 3:00 p.m. on 5/15/15 and 5/18/15. There was only one (1) RN on duty on the evening shift of duty on 5/13/15, 5/15//15, 5/16/15, 5/17/15 and 518/15 with the exception of one (1) additional RN from 3:00 to 6:30 p.m. on 5/15/ and 5/18/15. This staffing pattern failed to ensure that a registered nurse was available on the acute psychiatric unit at all times to provide active treatment to patients.

Based on observation, interview and document review, the Director of Nursing failed to staff sufficient numbers of nursing personnel on the Acute Psychiatric Unit based on the numbers and acuity needs of patients. This staffing was especially problematic when the majority or all patients were in their assigned rooms on the evening and night shifts of duty. These staffing patterns result in a lack of nursing personnel to provide on-going patient monitoring and potential safety risks for patients and staff.

Findings include:

A. The Acute Psychiatric Unit is a 16 bed unit with a patient census of 12 on the first date of the survey (5/18/15). It is a co-ed unit with up to 4 adolescent patients who are sent to the hospital for about 3-4 days on involuntary "detention" due to behavioral problems in the community. These adolescents are provided a complete psychiatric evaluation, medications as needed and then placed based on their needs, sometimes to an adolescent treatment facility.

Observation of the Acute Unit on 5/18/15 at 12:00 p.m. revealed that the unit has two long halls off of a main central patient area and nursing station. There are a total of five (5) large pods with both single and double patient bedrooms. This unit design has several areas (4 minimum) for viewing patient/rooms to ensure patient safety. Three of these patient pods are not visible from the nursing station area. Even when staff are making patient monitoring rounds (5-15 minute intervals based on patient needs), all patients and areas can not be viewed unless a staff member is immediately present. One of the sitting/television rooms (also used for small groups) and the occupational therapy room are located at the end of the female hall. In addition, the medication room is located in front of the next to last pod down near the end of the female wing.

B. On the first day of the survey, the patient census was 12. Of these 12 patients, 4 were male and 8 were female (including one 15 year old adolescent).

Review of the Patient Need Assessment for these 12 patients completed by nursing on the first day of survey (5/18/15) revealed that one patient was potentially assaultive, six (6) patients were a low risk for suicide and six (6) patients were an intermediate risk for suicide. Six (6) of these patients were constantly demanding of time, and nine (9) of the 12 patients required every 5 minute monitoring checks.

B. Review of the staffing schedule provided by the DON for the Acute Psychiatric Unit for 5/12/15 through 5/18/15 (first day of the survey) revealed that on the following dates and shifts of duty there was a deficit number of nursing personnel to provide monitoring needed to ensure patient safety:

a. On 5/12/15 there was 1 RN and 2 nursing technicians on the night shift of duty.

b. On 5/13/15 there was 1 RN and 2 nursing technicians on the evening shift of duty.

c. On 5/15/15 there was 1 RN and 2 nursing technicians on the evening shift from 6:30 to 11:00 p.m. and on the night shift of duty.

d. On 5/16/15 there was 1 RN and 2 nursing technicians on the day, evening and night shifts of duty.

e. On 5/17/15 there was 1 RN and 2 nursing technicians on part of the day shift and on the entire night shift of duty.

f. On 5/18/15 there was 1 RN and 2 nursing technicians on the night shift of duty.

D. Staff Interview and Patient Observation:

1. During interview on 5/18/15 at 12:00 p.m., RN 3 stated that the RN made the judgment about patient room assignment based on patient need and room availability, sometimes moving patients to other rooms. She stated that "adolescents are always assigned to a patient room alone in front of the nursing station."

Observations on the ward on 5/18/15 revealed that the only adolescent patient (active sample Patient #3) was assigned to a room near the end of the female wing. On 5/19/15 at 12:00 p.m., RN 1 verified that Patient #3 was assigned to this room (214) on the night of 5/18/15 and morning of 5/19/15, rather than a room across from the nursing station.

2. During interview on 5/18/15 at 12:00 p.m., RN3 reported that male patients are not supposed to go into the female area (wing) without staff supervision.

During Unit observations on 5/18/15 at 12:40 p.m., a male patient was observed "wandering" at the end of the female wing past the medication room. Observation at this time revealed that an adolescent patient (active sample Patient 3) was in her assigned bedroom (214) in the immediate vicinity.

During interview on 5/18/15 at 12:45 p.m. when asked about the male patient's presence down on the female wing, MHT 4 stated, "Males are not allowed to watch TV and congregate at that end of the hall." She added, "They (males) must go back in the female area (unit) to get medications and go to OT (Occupational Therapy)."