HospitalInspections.org

Based on a review of facility documentation, observation and staff interviews, the facility failed to ensure the treatment plan of each patient was updated after a significant change in status to reflect all active therapeutic efforts for the patient were included for 1 of 10 patients [Patient #1].

Findings were:

Facility policy #PC 01.03.01b, entitled "Treatment Team Planning," last reviewed 1/18, included the following:
"PURPOSE:
To ensure every patient receives an individualized treatment plan which communicates the current status and needs of the patient ...
POLICY: ...
Emergency Treatment Plans for special circumstances will be initiated as needed and the Master treatment Plan [sic] and problem sheets will be updated to reflect changes ...
12. The patient's treatment plan will be reviewed at least every 7 days from the initial Master Treatment Plan meeting and if clinically needed less than 7 days from the completion of the Master Treatment Plan and Treatment Plan Update ...
13. The case manager will document on both the Mater [sic] Treatment Plan or Treatment Plan Update the following:
- patient status
- changes in condition ...
- goal changes
- intervention changes
- medical issues ...
- therapy issues ..."

A review of the clinical record of Patient #1 revealed she was a 13-year-old female admitted to River Crest Hospital on an order of emergency detention on 10/2/18. An intake assessment on that date noted she had a history of physical abuse by her mother's boyfriend, but no sexual abuse was noted.

Nursing progress notes included the following:
o 10/6/18 at 1:00 a.m. - "Pt questioned regarding possible sexual incident/allegation. Nursing supervisor notified and police contacted. Pt moved to another room for safety ..."
o 10/6/18 at 8:00 a.m. - "awake, alert, verbal. Friendly & coop. C/o depression 4/10, anxiety 4/10. Denies SI, HI, hall & SIB (hallucination and self-injurious behavior). Denies physical issues. Slept well. Mood fair. Denies anger & aggression. Quiet & withdrawn ..."
o 10/6/18 at 9:15 a.m. - "To Shannon ER [with] staff for appt. made by police dept. for a rape kit exam ..."
o 10/6/18 at 7:50 p.m. - "Late Entry: Notified by Risk Manager (due to RN being unavailable) at 01:16 on this date that she was notified by house supervisor that a 16 year old male patient told staff he had sex [with] this patient. Once this information was received, the male patient remained in day room or in staff sight. This writer arrived at facility approximately 0200 and immediately met [with] house supervisor. House supervisor informed this writer that SAPD (San Angelo Police Department) had come to RCH (River Crest Hospital) and already left. Met [with] patient at 02:15 [with] [therapist]. Pt was tired and somewhat resistant to talking to this writer. Pt reported the [sic] she and 16 year old male peer had been talking for about an hour before lights out and continued talking from their doorways once it was bedtime. Patient reported that staff were up front in the hallway when she went into male peer's room. Patient reports she took her own clothes off. Pt reports they only had vaginal sex and it was while standing up. Pt reports she wanted to have sex [with] him and did not ever tell him no or to stop ...This writer asked patient if she had anything else she wanted to discuss, pt declined and interview was ended. At approximately 03:30 on 10/6/18, [detective] arrived, completed interviews and spoke to patient grandmother. This writer called grandmother at 0605 on this date ..."

A medication consent for "Plan B" was documented on a psychotropic medication consent on 10/6/18 at 4:55 a.m. with telephone consent for the medication to be administered provided by the patient's grandmother. It was witnessed by two registered nurses and signed by a physician.

An Interdisciplinary Master Treatment Plan initiated on 10/3/18 for Patient #1 included no update after this significant incident and change in status. Patient #1 was discharged on 10/8/18.

In an interview with Staff #1, Director of Quality/Performance Improvement on the afternoon of 10/15/18, she acknowledged the treatment plan of Patient #1 was not updated after this significant occurrence/change in status, and that it "should have been."