HospitalInspections.org

(Translation assisted by Hospital Director of QI)

Based on interview and record review, it was determined that the facility failed to provide social work assessments that included recommendations for social work role in treatment and discharge planning for 8 of 8 active sample patient records (A, B, C, D, E, F, G, and H). This failure resulted in an absence of coordinated, specific professional social work treatment services which seriously compromises treatment and discharge planning for the patient

Findings include:

A. Record Review:

1. Patient A: Patient admitted 10/22/10. In a Psychosocial Assessment dated 10/22/10, it stated under "Plan De Treatmento" (treatment plan): "stabilize Sx [symptoms], prevention of relapse." No recommendations for specific social work interventions were listed.

2. Patient B: Patient admitted 10/23/10. In a Psychosocial Assessment dated 10/24/10, it stated under "Plan De Treatmento": "Stabilize Sx, Prevention of relapse, Goalsetting, Continue treatment ambulatory psychiatric and psychologic Treatment [sic]" No recommendations for specific social work interventions were listed.

3. Patient C: Patient admitted 10/23/10. In a Psychosocial Assessment dated 10/23/10, it stated under "Plan De Treatmento": "Stabilize Sx, Control of impulses, Treatment ambulatory psychiatric." No recommendations for specific social work interventions were listed.

4. Patient D: Patient admitted 10/25/10. In a Psychosocial Assessment dated10/25/10, it stated under "Plan De Treatmento": "Stabilization of symptoms, Control of Impulses, Continue treatment ambulatory psychiatric and psychologic." No recommendations for specific social work interventions were listed.

5. Patient E: Patient admitted 10/24/10. In a Psychosocial Assessment dated 10/25/10, it stated under "Plan De Treatmento": "Stabilization of symptoms, Control of Impulses, Continue treatment ambulatory psychiatric and psychologic." No recommendations for specific.

6. Patient F: Patient admitted 10/20/10. In a Psychosocial Assessment dated 10/21/10, it stated under "Plan De Treatmento": "Stabilization of symptoms, Control of Impulses, Continue treatment." No recommendations for specific social work interventions were listed.

7. Patient G: Patient admitted 10/25/10. In a Psychosocial Assessment dated 10/26/10, it stated under "Plan De Treatmento": "Stabilization of symptoms, Control of Impulses, Continue treatment ambulatory." No recommendations for specific social work interventions were listed.

8. Patient H: Patient admitted 10/20/10. In a Psychosocial Assessment dated 10/21/10 it stated under "Plan De Treatmento": "Stabilization of symptoms, Control of Impulses, Continue treatment ambulatory." No recommendations for specific social work interventions were listed.

B. Interview

In an interview on 10/28/10 at 3:00PM with the Director of Social Services and the Director of Quality Improvement (who facilitated as an interpreter), both Directors concurred with the findings.

Based on interviews and record review it was determined that the hospital failed to document neurological examinations in such a way as to verify specific testing performed in 8 of 8 active sample patient records ( A, B, C, D, E, F, G, and H ). This failure to document current status precludes diagnosis of concurrent neurologic disorders and future comparative re-examinations to assess the patients' ongoing functioning.

Findings include:

A. Record Review:

(The physical examination is in a check list format)

1. Patient A. Patient admitted 10/22/10. Physical Examination dated 10/22/10, in the section: "Systema Neurolgico" (Neurology System),which included "Functiones Generales", "Functiones especificas," "Nervios craniales," "Functiones sensorales," and "Tono y masa muscular," reported "no deficit" No mention of methods of testing by which findings were determined was made.

2. Patient B. Patient admitted 10/23/10. Physical Examination dated 10/23/10 reported no gross or sensory deficit.in the section: "Systema Neurolgico," No mention of methods of testing by which findings were determined was made.

3. Patient C: Patient admitted 10/23/10. Physical Examination dated 10/23/10 reported "No Deficit" written in the section "Systema Neurolgico." No mention of methods of testing by which findings were determined was made.

4. Patient D: Patient admitted 10/25/10. Physical Examination dated 10/25/10 reported "No Deficit" in the section: "Systema Neurolgico." No mention of methods of testing by which findings were determined was made.

5. Patient E: Patient admitted 10/24/10. Physical Examination dated 10/24/10 reported "No gross focal deficit" in the section: "Systema Neurolgico" No mention of methods of testing by which findings were determined was made.

6. Patient F: Patient admitted 10/20/10. Physical Examination dated 10/20/10 reported "NO" in the section: "Systema Neurolgico". No mention of methods of testing by which findings were determined was made.

7. Patient G: Patient admitted 10/25/10. Physical Examination dated 10/25/10 reported "No gross focal deficit" in the section: "Systema Neurolgico" No mention of methods of testing by which findings were determined was made.

8. Patient H: Patient admitted 10/20/10. Physical Examination dated 10/20/10 reported no gross focal deficit in the section: "Systema Neurolgico" No mention of methods of testing by which findings were determined was made.

B. Interviews:

1. In an interview with the Medical Director and the Director of Quality Improvement (who facilitated as an interpreter) on 10/28/10 at 4:00PM both Directors concurred with the findings.

2. In an interview with M.D. #1, acting attending psychiatrist of patient D, on 10/29/10 at 10:30AM M.D. #1 concurred with the findings noted above.

Based upon interviews and record review, the hospital failed to assure the reporting of memory functioning in measurable, behavioral terms, and/or the method by which the conclusions were reached, which clearly reflected the patients' ability to function in those areas for 8 of 8 active sample patients. (A, B, C, D, E, F, G, and H). This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

The Mental Status Examination is in a checklist format which provided three options: "Buena," (good) "Regular," (normal) and "Deteriorada" (deteriorated) for "Memoria" (Memory) reporting.

A. Record Review:

1. Patient A: Patient admitted 10/22/10. In Psychiatric Evaluation dated 10/23/10 it was noted under the section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena" (good), "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined nor were the terms "Buena," "Regular," and "Deteriorada" measurable or behavioral.

2. Patient B: Patient admitted 10/23/10. In Psychiatric Evaluation dated 10/24/10 it was noted under section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena," "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined, nor were the terms "Buena", "Regular," and "Deteriorada" measurable or behavioral.

3. Patient C: Patient admitted 10/23/10. In Psychiatric Evaluation dated 10/23/10 it was noted under section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena," "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined, nor were the terms "Buena," "Regular," and "Deteriorada" measurable or behavioral.

4. Patient D: Patient admitted 10/23/10. In Psychiatric Evaluation dated 10/25/10 it was noted under section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena," "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined nor were the terms "Buena," "Regular," and "Deteriorada" measurable or behavioral.

5. Patient E: Patient admitted 10/24/10. In Psychiatric Evaluation dated 10/25/10 it was noted under section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena," "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined nor were the terms "Buena," "Regular," and "Deteriorada" measurable or behavioral.

6. Patient F: Patient admitted 10/20/10. In Psychiatric Evaluation dated 10/20/10 it was noted under section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena," "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined nor were the terms "Buena," "Regular," and "Deteriorada" measurable or behavioral.

7. Patient G: Patient admitted 10/25/10. In Psychiatric Evaluation dated 10/25/10 it was noted under section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena," "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined nor were the terms "Buena," "Regular," and "Deteriorada" measurable or behavioral.

8. Patient H admitted 10/2425/10. In Psychiatric Evaluation dated 10/25/10 it was noted under section "Mental Status Examination" the following: "Immediata Memoria" (Immediate Memory) as "Buena," "Reciente Memoria" (Recent Memory) as "Buena", and "Pasada Memoria" (Past Memory) as "Buena." No mention was made of methods by which the conclusions were determined nor were the terms "Buena," "Regular," and "Deteriorada" measurable or behavioral.

B. Interviews:

1. In an interview with the Medical Director and the Director of Quality Improvement (who facilitated as an interpreter) on 10/28/10 at 4PM surveyor presented the above findings. Both Directors acknowledged the findings.

2. In an interview with M.D. #1, acting attending psychiatrist of patient D, on 10/29/10 at 10:30AM surveyor presented the above findings. M.D. #1 agreed with the findings

Based on record review and staff interview, the nurses and physicians failed to document on the Master Treatment Plan specific planned treatment interventions which were based on the individual needs of 8 of 8 active sample patients (A, B, C, D, E, F, G, and H). Each goal on the plan was accompanied by preprinted modalities that failed to describe the specific focus for treatment for each modality. This failure to document specific treatment approaches on the plan interfered with the assurance of a consistent approach to each patient's problem.

Findings include:

A. Record Review:

The Treatment Plans for 8 of 8 active sample patients (A, B, C, D, E, F. G, and H) stated the same nursing interventions for each listed problem. The interventions were in a check list format, with a different checklist for each category of problem The checklist was the same for all of the following examples

1. Seven ( A, B, C, D, E, F and H) of 8 Active Sample patients had treatment plans that addressed suicide ideas ("Ideas suicidas") as a problem and included the same RN interventions without individualized specific focus for each patient. The "Intervenciones" were "Administrar medicamentos seguin ordenes MD; Observar efectividad de medicamentos; Identificar efectos secundarios; Educar a cliente sobre medicamentos; Promover estrategias saludables para manejar estresares; Observe comportamiento; orientar a la realidad; Mantener un ambiente seguro; Ofrecer apoyo emocional y facilitar la verbalizacion de sentimeintos y obserar efectividad de medicamentos." The last intervention labeled "Otro" (Other) was blank.

2. Eight of 8 sample patients (A, B, C, D, E, F, G and H) all had treatment plans that addressed psychosis ("Psycosis") as a problem and included the same RN interventions and lacked a specific focus for each patient. The "intervenciones" were "Administrar medicamentos segun ordenes MD; Observe efectividad de medicamentos; Identificar efectos secundarios; Educar a cliente sobre medicamentos; Promover estrategias saludables para menejar estresores; Observar comportamiento; Mantener un ambeiente seguro; Orientar a la realidad; Estimular a cliente a participar en las actividades terapeuticas; Reforzar aproximaciones a expresar sentimientos frustraciones, conflictos apropiadamente." The last intervention labeled "Otro" (Other) is blank.

3. Four of the 8 sample patients (E, F, G, and H) had treatment plans that addressed aggression/problem control of impulses ("Agresividad/Pobre control de impulses") as a problem and each included the same RN interventions and lacked a specific focus for each patient. The "intervenciones" were "Administrar meducamentos segun ordenes MD; Observe efectividad de medicamentos; Identificar efectos secundarios; Educar a cliente sobre medicamentos; Promover estrategias saludables para manejar estresores; Observar comportamiento; Mantener un ambiente seguro; Ofrecer apoyou emocional y facilitar la verbalizacion apropiada de sentimientos y preocupaciones; Estimular a cliente a participar en las actividades terapeuticas, Definir lities y consecuencias de conducta agresiva con claridad mientras le facilite la expression de sentimientos." The last intervention labeled "Otro" (other) is blank.

B. The Treatment Plans for 8 of 8 sample patents (A, B, C, D, E, F, G, and H) stated the physician interventions in a checklist format and were not specific to patient need. The physician areas of the Treatment Plans for 3 (C, F, and H) of the 8 sample patients were not checked for any of the standardized check list interventions.

1. Sample Patient C Treatment Interventions for Psychosis ("Psicosis") were: "identificar factores de riesgo hacia llevar a cabo accion destructive; Evaluar la intensidad de confusion, alucinaciones, pensamiento LLogico, capacidad para comprobar la realidad, motivacion, memoria, juicio, Limitaciones para la socializacion. Ordenar medicamentos y evaluar efectividad. RX.[blank]." (Prescribed medications not documented; the area was blank)

2. Sample Patient F Treatment Interventions for Suicide ("Ideas suicidas") were: "Intervenciones individuals [blank] dias a la semana por [blank] horas con el proposito de Evaluar ideacion suicida, homicida o hacer dano a otra persona o a la proiedad; Identificar factores de riesgo hacia llevar a cabo accion destrctiva; Evaluar la intendidad de confusion, alucinacione, pensamiento Ilogico, Capacidad para comprobar la realidad, Otros; Ordenar medicamentos y evaluar efectividad; RX [blank]." (Prescribed medications not documented. Area was blank)

3. Sample Patient H. Treatment Interventions for Aggression/Impulse Control ("Estrategias Terapeuticas Accion Para Lograr reduccion de sintomas") were:"Intervenciones individuals [blank] dias a la semana por [blank] horas con el proposito de evaluar la intensidad de confusion, alucinaciones pensamiento llogico, capacidad para comprobar la realidad;.ordenar medicamentos y evaluar efectividad; RX[blank]." (Prescribed medications not documented.)

The Treatment Plans for 8 of 8 sample patents (A, B, C, D, E, F, G, and H) did not include the medications prescribed by the physician

.B. Staff Interview:

1. In an interview on 10/29/10 at 3:30PM, with the Director of Nursing (DON) through an interpreter the Nursing portions of the Treatment Plans were discussed. The surveyor gave examples of how the nursing treatment plans failed to document a focus of interventions based on the individual needs of each patient. With the assistance of an interpreter, the DON agreed with findings

2. In an interview on 10/29/10 at 3:55PM with the Medical Director and the Director of Quality Improvement, the lack of specific and measureable therapeutic treatment intervention/documentation in the treatment plans by the physicians and nurses was discussed. The Medical Director and the Director of Quality Improvement both concurred with the findings.

Based on interviews and record review it was determined that the Medical Director failed:

1. To assure that physical examination records reported neurologic findings in such a way as to verify specific testing performed and concurrent neurologic disorders;

2. To assure the reporting of memory functioning in measurable, behavioral terms and/or the method by which the conclusions were reached;

3. To assure the documentation of specific physician treatment approaches on the treatment plans.

Findings include:

1. Based on interviews and record review it was determined that the hospital failed to document neurological examinations in such a way as to verify specific testing performed in 8 of 8 active sample patient records (A, B, C, D, E, F, G, and H ). This failure to document current status precludes diagnosis of concurrent neurologic disorders and future comparative re-examinations to assess the patients' ongoing functioning. (Refer to B109)

2. Based upon interviews and record review, the hospital failed to assure the reporting of memory functioning in measurable, behavioral terms, and/or the method by which the conclusions were reached, which clearly reflected the patients' ability to function in those areas for 8 of 8 active sample patients (A, B, C, D, E, F, G, and H). This failure compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

3. Based on record review and staff interview, the nurses and physicians failed to document specific treatment interventions on the Master Treatment Plans based on the individual needs of 8 of 8 active sample patients (A, B, C, D, E, F, G and H). Each goal listed on the plans was accompanied by preprinted modalities that failed to describe the specific focus for treatment for each modality. This failure to document specific treatment approaches on the plans interferes with the assurance of consistency of approach to each patient's problem. (Refer to B122)

Based on record review and interview, the Director of Nursing failed to develop individual nursing interventions for 8 of 8 active sample patients (Patients A, B, C, D, E, F,G and H). This failure prevented nursing personnel from providing consistent direction, approach, and focused treatment.

Findings include:

A. Record Review:
Treatment Plans for 8 of 8 sample patients (A, B, C, D, E, F, G, and H) stated the same check list nursing interventions for any stated problem. The interventions for suicidal ideation were in the form of a checklist that was the same for all sampled patients. The nursing interventions for the problem of psychosis were in the form of a check list that was the same for all 6 sampled Patients who had this problem identified on the treatment plan (Patients A-F).Treatment Plans for the 4 of 8 sampled patients (E,F,G, and H) with the problem of aggression stated the same nursing interventions in the form of a checklist (See B122)

Interview:

In an interview on 10/28/10 at 1:30PM with the DON and an interpreter, the DON agreed with the findings.

Based upon record review and interviews it was determined that the Director of Social Work failed to assure the provision of Social Work Assessments which included recommendations for the Social Work role in treatment and discharge planning. This failure resulted in an absence of coordinated specific professional social work treatment services which seriously compromises treatment and discharge planning for the patient. (Refer to B108)