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Based on record reviews and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice is evidenced by failure of the RN to ensure a patient's Psychiatric Intake Assessment was assessed accurately for 1(#2) of 5 (#1-#5) patients reviewed for Psychiatric Intake Assessments and failure to ensure suicide risk and homicide/violence risk was assessed accurately on the SRA/Homicide/Violence Risk Assessment tool, as per hospital policy, for 2 (#2, #5) of 5 (#1-#5) sampled patients' records reviewed for SRA/Homicide/Violence Risk Assessments from a total patient sample of 6 ( #1-#5, #R1).

Findings:

Review of the hospital policy titled, "Suicide/Homicide Risk Assessment", Policy number: AS-19, revealed in part: Purpose: To establish guidelines for the identification of individuals who are actively suicidal and/or homicidal and intervene in a manner to ensure safety for all.
Policy: The hospital will assess and identify safety risks inherent in the facility's client population and identify those clients of high risk potential for suicide/homicide. Suicide/Homicide assessments are conducted at first contact and with any subsequent suicidal/homicidal behavior, increased ideation or pertinent clinical change. Assessment is not to predict outcome, but rather to make a logical assessment of a prevailing risk of violence to self or others and to develop a reasonable treatment plan to provide psychiatric services. Factors that may increase/decrease risk will be identified and assessed to provide for the individuals safety needs and appropriate placement.
Procedure: Nursing Staff: During the admit assessment, clinical staff will assess risks/protective factors. Nursing staff will: a. Note those risks which can be modified with appropriate interventions, b. Note those protective/deterrent factors indicated which can be enhanced with appropriate interventions, c. Conduct a suicide/homicide screening assessing thoughts, plans, behaviors, and intents, d. Determine suicide/homicide risk level and choose appropriate intervention to address and reduce/mitigate the risk, and e. Document assessment of risk rationale, intervention, and follow-up in the patient's medical record.


Patient #2
Review of Patient #2's medical record revealed an admission date of 6/5/19 with admission diagnoses including Depression with Suicidal Ideation. Further review revealed the patient's legal status was PEC/CEC due to being suicidal, dangerous to self, and unable to seek voluntary admission. Additional review of the CEC revealed the patient had wrapped a phone cord around her neck in an attempt to strangle herself and had command hallucinations telling her to kill herself because no one loved her.

Review of Patient #2's admit Psychiatric Intake Assessment, dated 6/5/19 at 6:15 p.m., revealed the following, in part: Presenting problems: Pt. reports severe Depression with Suicidal Ideation, Emergency Room nurse reports pt. with auditory hallucinations commanding the patient to kill herself by strangulation.

Further review revealed the following: Current Symptoms: Gravely Disabled, Depression, Actively Homicidal: marked "No." Actively suicidal: with plan: marked "No". At risk symptoms: History of suicide attempts /gestures within the last 6 months: marked "No" (patient had attempted suicide immediately prior to admission). Current precautions: Suicidal. The intake was completed by S4RN.

Review of the Admit Nursing Assessment dated 6/5/19 at 6:15 p.m. revealed the following, in part: Reason for admission: "Having thoughts of suicide that started this morning, attempted to strangle self - boyfriend stopped me." Reports still hearing voices continuing hallucinations. Mood depressed tearful, thought processes: organized; Perceptions/hallucinations: left blank.

Review of the section titled, "Suicide Risk Level Screen" of the Admit Nursing Assessment revealed another section titled, "Risk Factors" indicating all risk factors that applied to the patient, from the list, should be checked. Further review revealed choices indicating past attempts/rehearsals (suicide) was left blank. Additional review revealed a box to be checked indicating if the patient had at least 2 key symptoms (risk factors) of the following: anhedonia, hopelessness, anxiety, panic, insomnia, command hallucinations, impulsivity and/or rapid mood shifts. Patient #2 had command hallucinations to kill herself, anxiety issues, and feelings of hopelessness ("nobody loves me") and the key symptoms box had not been checked.

Review of the section titled, "Ranking for Suicide Risk Level" of the suicide risk screening tool revealed the patient's suicide risk level was determined based upon assessment of the patient's risk factors, protective factors, and suicidality. Additional review revealed the patient's scores for suicide risk level were classified as "High Risk - Notify psychiatrist of high risk level for further clarification"; "Moderate Risk: implement q 15 minute observations; monitor for changes in states"; " Low Risk-implement q 15 minute observation"; or " Not a clinical issue: implement q 15 minute observations". Review of this portion of Patient #2's Suicide Risk Level Screen revealed the section was left blank and had not been scored by S5RN.

In an interview on 6/10/19 at 2:18 p.m. with S1Adm, she confirmed Patient #2's SRA and Psychiatric Intake Assessment documentation was inaccurate and further confirmed the SRA risk level screen had not been accurately assessed. S1Adm verified no scoring had been performed to determine Patient #2's suicide risk level. S1Adm indicated the inaccurate assessment left her with no documentation to show whether the patient may have needed a higher level of observation.

In an interview on 6/11/19 at 8:15 a.m. with S5RN, she confirmed the RN on the unit performed newly admitted patient's initial suicide risk assessments. S5RN verified past history of suicide attempts was to be taken into account when scoring a patient's level of suicide risk. S5RN confirmed she had admitted Patient #2. S5RN further confirmed, after review of Patient #2's record, that she had not accurately completed Patient #2's suicide risk assessment and had failed to score the patient's suicide risk level. S5RN reported Patient #2 had begun crying and she had put the paperwork down, with the intention of finishing it later, and had forgotten to finish the assessment.

In an interview on 6/11/19 at 9:39 a.m. with S4RN, she reported SRAs were done at admission and all patients were asked if they were suicidal, but initially, during admit, patients may not want to talk. S4RN confirmed she had completed Patient #2's admit Psychiatric Intake Assessment on 6/5/19 at 6:15 p.m. S4RN reported she tried to fill out as much information as possible from the patient's hospital referral information. S4RN confirmed she had not done a face to face interview with the patient. S4RN reviewed Patient #2's Psychiatric Intake Assessment and acknowledged there were errors in the documentation such as marking "No" to the question is the patient actively suicidal with a plan and marking history of suicide attempts /gestures within the last 6 months "No". S4RN reported she had no other explanation other than she made a mistake and indicated sometimes she is too fast for her own good.


Patient #5
Review of Patient #5's medical record revealed an admission date of 6/10/19 with admission diagnoses including past medical history of Schizophrenia, psychosis, mania.

Further review revealed Patient #5's legal status was PEC on 6/8/19 at 11:10 p.m. due to being in a manic state, acutely psychotic, delusional, non -compliant with medications (for Schizophrenia), aggression, and agitation. Additional review revealed the patient was documented as violent, dangerous to others, unwilling to seek voluntary admission, and gravely disabled.

Review of the patient's CEC documentation, dated 6/11/19 at 3:10 p.m., revealed the patient had been delusional, agitated, and labile and had required multiple PRNs in the ED due to aggression.

Review of Patient #5's Psychiatric Intake Assessment documentation revealed the patient had been violent toward others within the last 6 months and had been OPC'd due to being very aggressive toward family, acutely psychotic, and manic.

Review of the portion of Patient #5's Admit Nursing Assessment, dated 6/11/19, titled, "Homicide/Violence Risk Level" revealed the "Risk Factors" section had been left blank. Review of the choices for risk factors revealed Personality Disorder and Symptoms of Loss of Control related to mania and delusions were not checked and should have been chosen based upon the patient's presentation at admit and past history.

Review of the section titled, "Rank your conclusion regarding Homicide Risk Level" of the homicide/violence risk screening tool revealed the patient's homicide/violence risk level was determined based upon assessment of the patient's risk factors and deterrent factors- internal and external. Additional review revealed the patient's scores for homicide risk level were classified as "High Risk - Notify psychiatrist of high risk level for further clarification"; "Moderate Risk- implement q 15 minute observations; monitor for changes in states"; " Low Risk-implement q 15 minute observation"; or " Not a clinical issue: implement q 15 minute observations". Review of this portion of Patient #2's Homicide/Violence Risk Level Screen revealed the patient's homicide/violence risk level had been scored as "Not a clinical issue: implement q 15 minute observations." Additional review of the form revealed the following statement regarding assessment of level of risk: Assessment level of risk is based on clinical judgement after completing screening of risk factors and protective factors.

In an interview on 6/11/19 at 1:30 p.m. with S1Adm, she confirmed, after review of Patient #5's medical record, that the patient's Homicide/Violence Risk Level Screen had not been completed, based upon the patient's history and presentation, and had not been accurately scored.

Based on record review and interview, the hospital failed to ensure each patient had a comprehensive, individualized treatment plan. This deficient practice was evidenced by:
1) failing to initiate a problems related to violent/aggressive behavior (present on admit) and patient cutting behavior (present on admit) on patients' treatment plans for 3 (#1, #3, #R1) of 6 (#1-#5, #R1) patient records reviewed for comprehensive treatment planning from a total patient sample of 6 (#1-#5, #R1); and
2) failing to update patients' treatment plans with behavior changes (aggression requiring administration of a PRN for behavior control) for 2 (#5, #R1) of 2 patient records reviewed for treatment plan revision from a total patient sample of 6 (#1-#5, #R1).

Findings:

Review of the policy titled "Treatment Planning; Integrated/Multidisciplinary ", presented as a current policy by S1Adm, revealed the following, in part: Policy: The multidisciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive treatment plan with specific goals and objectives necessary to address deficits identified in the assessment process and continual development and formulation by the attending physician and multidisciplinary treatment team., with the patient's involvement, through the course of treatment. The treatment plan includes defined problems and needs, measureable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. Procedure: 2. The admitting nurse is responsible for the following: a. Ensure that this preliminary plan of care addresses presenting needs, b.Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs strengths, and limitations, physician's orders, and c. Revising the plan based on changes in condition and physician's orders will be added to the treatment plan.

1.Failing to initiate a problem, present on admit, in the treatment plan:

Patient #1
Review of Patient #1's medical record revealed an admission date of 5/16/19 and a discharge date of 5/2/19 with admission diagnoses including unspecified Psychosis not due to a substance or known psychological condition, Paranoid schizophrenia, and Bipolar Disorder.

Further review revealed Patient #1's legal status was PEC/CEC due to being off of medications, exhibiting bizarre behavior, positive for auditory hallucinations, threatening and pushing on his mother. Additional review revealed the patient was documented as being dangerous to others, gravely disabled, and unwilling/unable to seek voluntary admission. The patient had also been OPC'd by the Coroner per the patient's mother's request.

Review of Patient #1's Psychiatric Evaluation, dated 5/2/19 at 9:10 p.m., revealed the following, in part: 47 year old male under PEC/CEC and OPC per mother due to bizarre behavior, auditory hallucinations, and aggression.

Review of Patient #1's physician's progress notes revealed the following entry, dated 5/4/19: Pt. had reportedly become increasingly violent and aggressive at home and was placed on OPC.

Review of Patient #1's Multidisciplinary Integrated Treatment Plan revealed potential for Violent/Aggressive Behavior (due to history of aggressive behavior on admit) had not been identified as a problem to be addressed on the patient's comprehensive plan for treatment.

Patient #3
Review of Patient #3's medical record revealed an admission date of 6/4/19 with diagnoses including Schizophrenia and Bipolar Disorder. Further review revealed Patient #3's legal status was PEC/CEC on 6/4/19 due to the Pt. hallucinating, with paranoid delusions and carrying a dagger. Further review revealed the patient was documented as being dangerous to others, gravely disabled, unwilling/unable to seek voluntary admission. Additional review revealed the patient had been threatening the neighbors.

Review of Patient #3's Psychiatric Intake Assessment revealed the patient was noted to have a violence risk toward others.

Review of Patient #3' q 15 minute observation sheets revealed the pt. was on violence/homicide precautions.

Further review of Patient #3's medical record revealed Patient #3 had scored a Moderate Homicide/Violence Risk Level score due in part to having aggressive ideation with a plan.

Review of Patient #3's Multidisciplinary Integrated Treatment Plan revealed potential for Violent/Aggressive Behavior (due to history of aggressive behavior on admit and Homicide/Violence Risk Level of Moderate) had not been identified as a problem to be addressed on the patient's comprehensive plan for treatment.

Patient #R1
Review of Patient #R1's medical record revealed an admission date of 5/1/19 with admission diagnoses of Schizophrenia and Bipolar Affective Disorder. Further review revealed the patient's legal status was PEC/CEC (PEC 4/30/19) due to being currently violent, dangerous to others, gravely disabled, unwilling/unable to seek voluntary admission. Additional review revealed the patient had self-harm behaviors of cutting her arm (left arm) indicating she had "cut herself so she would not harm others."

Review of Patient #R1's Multidisciplinary Integrated Treatment Plan revealed self-harm behaviors related to cutting had not been identified as a problem to be addressed on the patient's comprehensive plan for treatment.

In an interview on 6/11/19 at 1:00 p.m. with S1Adm, she confirmed the above referenced behaviors should have been addressed as problems on Patient #1, Patient #3, and Patient #R1's Multidisciplinary Integrated Treatment Plan and verified they had not been addressed.


2. Failing to update/revise patients' treatment plans:

Patient #5
Review of Patient #5's medical record revealed an admission date of 6/10/19 with admission diagnoses including a past medical history of Schizophrenia, with current psychosis and mania.

Further review revealed Patient #5's legal status was PEC on 6/8/19 at 11:10 p.m. due to being in a manic state, acutely psychotic, delusional, non - compliant with medications (for Schizophrenia), aggression, and agitation. Additional review revealed the patient was documented as violent, dangerous to others, unwilling to seek voluntary admission, and gravely disabled.

Review of Patient #5's nurses' notes revealed the following entry, dated 6/11/19 at 7:58 a.m.: PRN administered due to pt. very labile, screaming, banging on windows of nursing station, refusing p.o. (by mouth) medications. IM administered - Ativan 2 mg, Haldol 5 mg, and Benadryl 25 mg, per PRN order.

Review of Patient #5's Multidisciplinary Integrated Treatment Plan revealed the patient's aggressive behaviors, requiring administration of PRN medications for control of the behaviors, was not identified as a problem to be addressed on the patient's plan of care.


Patient #R1
Review of Patient #R1's medical record revealed the following nurses' note entry: 5/3/19: IM PRNs administered as ordered after 20 mg Zyprexa, PRN by mouth, did not control patient's screaming. Pt. talking in male and female voices and screaming that she was a demon and she was possessed by the devil, wanting to fight other pts. Zyprexa 10 mg IM administered as PRN, Benadryl 50 mg IM also administered. Meds (medications) did not stop patient's behaviors. Doctor notified and Ativan injection administered IM as ordered as a PRN medication.

Review of Patient #R1's Multidisciplinary Integrated Treatment Plan revealed the patient's aggression/violent behavior requiring administration of multiple PRN medications for behavioral control was not identified as a problem to be addressed on the patient's plan of care.

In an interview on 6/11/19 at 12:47 p.m. with S2DON, she confirmed aggressive/violent behaviors had not been identified as problems to be addressed on Patient #5 and Patient #R1's treatment plans. S2DON confirmed the treatment plans should have been revised to address the above referenced behaviors requiring administration of PRN medications for control of the behaviors.