HospitalInspections.org

Based on record review and interviews, the facility failed to ensure that comprehensive treatment plans were formulated for 2 of 8 active sample patients (N3 and W8) that addressed all acute or new-onset medical problems. The absence of an integrated, comprehensive treatment plan that includes medical issues needing treatment during the hospitalization results in delay in the recognition and provision of timely treatment of co-occurring medical conditions in patients already compromised by psychiatric illness.

Findings include:

A. Active sample patient N3

1. N3 was admitted to the facility on 6/17/12. On admission, in addition to psychiatric problems, the patient presented with a raised, erythematous, and pruritic rash on both forearms, leading the doctor performing the Admission Physical Exam (dated 6/17/12) to question whether the rash was the manifestation of sun poisoning or toxic dermal necrolysis. In the assessment/plan section of the Physical Exam, the examining physician wrote: "? sun 'allergy' or toxic dermal necrolysis...will rx [treat with] prednisone x 2 more days."

2. When the team convened to develop the Master Treatment Plan on 6/18/12, the attending psychiatrist did not ensure that the rash on the patient's forearms would be included on Axis III as a substantiated diagnosis or identified as a problem to be addressed with specific nursing and medical interventions.

3. The problem, "Rash both arms as evidenced by red raised rash, itching" was added to the Master Treatment Plan on 6/19/12, with only the following nursing interventions developed: "monitor for S/S [signs and symptoms] infection" and "monitor effects of medication." No interventions by the team psychiatrist or non-psychiatric medical personnel were documented for ongoing evaluation or treatment of the rash.

4. A referral for a "medicine consult re pain + rash" was mentioned for the first time in a Psychiatry Daily Clinical Note of 6/20/12. However, identified goals and medical interventions were still not added to the Master Treatment Plan when reviewed by the surveyor later in the day on 6/20/12 and again on 6/21/12.

5. In an interview on 6/20/12 at 10:30a.m., patient N3 stated that the rash was still causing distress and "bothering me." The patient also said, "I feel like I've been forgotten...they told me I would see the medical doctor yesterday and then promised me I would see the doctor today."

B. Active sample patient W8

1. W8 was admitted to the facility on 6/8/12. The problem, "new-onset repeated refusal to take fluids and food by mouth" was identified by nursing on 6/09/12. The problem was documented in the following Interdisciplinary Progress Notes:

(6/9/12; 1330 (1:30 p.m.): "without fluid and without food intake. Refused O.J [orange juice] ...Lunch without intake food or fluids"
(6/9/12; 2240 (10:40p.m.): "Refused meal...."
(6/10/12; 1330 (1:30p.m.): "Pt declined offered meals...despite encouragement from staff"
(6/10/12; 2245 (10:45p.m.): "Pt was non compliant with meals and fluids prior to 2225 (10:25 p.m.) trip to dining room"
(6/11/12; 1437 (2:37p.m.): "Pt has refused all offered groups, meds and meals..."
(6/12/12; 1306 (1:06p.m.): "Pt refused all meds and meals."
(6/13/12; 1530 (3:30p.m.): "...in bed most of the day did take fluids po but no food..:
(6/14/12; 2200 (10p.m.): "During dinner time pt walked down to dining room stared at her plate of food but did not eat one bite."
(6/20 [no year noted]; 1350 (1:50p.m.): "pt has refused all meals today. Pt also refused all offered liquids."

2. The Master Treatment Plan developed on 6/11/12 did not identify the patient's problem with food and fluid intake, and did not delineate specific interventions to be taken by designated nursing and medical personnel.

3. The Master Treatment Plan was reviewed by the treatment team on 6/18/12 at 1:30p.m. The review did not result in any plan revisions/updates to include the patient's fluid and food intake problem.

4. In an interview on 6/20/12 at 2:20p.m., when asked what the main concerns and interventions were for active sample patient W8, RN1 responded, "Hydration and meds." When asked whether the patient's refusal to take fluids and eat were on the Master Treatment Plan, RN1 responded, "No, they're not...they should be there for both nursing and medical (staff)."

5. In an interview on 6/21/12 at 9:40a.m., MD2 was asked if documentation regarding patient W8's refusal to drink and eat had been added to the Master Treatment Plan once it was noted as a persisting problem by nursing staff, and whether the Master Treatment Plan included patient goal(s) and intervention(s) to be provided by designated team members, MD2 stated "No...I didn't feel it was a problem."