HospitalInspections.org

Based on observation, interview, record review and facility policy review, the facility failed to ensure five patients (#38, #39, #40, #54 and #79) of five patients reviewed in the facility psychiatric units had nursing care plans developed based on the individual patient's needs.
One pregnant patient (#38), three patients (#39, #40 and #54) who had infections, and one patient (#79) had the potential for drug and alcohol withdrawal, did not have care plans that identified the individual needs of the patients. The failure effects all patients admitted to the psychiatric services units of the facility. The facility census was 848; the psychiatric unit census was 39.
Findings included:
1. Record review of the facility's policy titled, "Documentation: Nursing" revised on 06/12, showed guidelines for Registered Nurse (RN) documentation for all areas of the facility performing nursing care. Specific documentation guidance for RN included the development of the Plan-of-Care based on the individual patient's needs/status with appropriate goals, approaches to care and outcomes related to the patient's initial and ongoing assessment findings.

2. Observation on 10/29/13 at 1:40 PM in the Adult Unit showed Patient
#38 resting quietly in room #15349 which was located within 10 feet of two exit doors at the end of the hall and not in direct line of sight of the staff/nurse station or activity room. Signs which read "high elopement risk" were posted on the entrance/exit doors of the unit and also on the outside of the patient's room.

3. During an interview on 10/29/13 at 1:40 PM Staff VV, RN Psychiatric Services Manager, stated that Patient #38 was a very high elopement risk, had been observed trying to get out (elope) of the exit doors, was seven months pregnant and was scheduled for court 10/29/13. Staff VV stated that the patient's room assignment should not have been close to the exit doors and should have been located closer to the nurse station due to the pregnancy and elopement risks.

4. Record review of Patient #38's medical record showed:
- The patient was seven months pregnant.
- She was admitted involuntarily (court ordered, in the facility against her wishes) on 10/04/13.
- A psychiatric admission assessment that included self injurious behaviors, homicidal thoughts (likely to kill someone, or wanting to kill someone), psychosis (a psychiatric disorder such as schizophrenia or mania that is marked by delusions, hallucinations, incoherence, and distorted perceptions of reality) and she required close observation.
- There was no plan of care for the patient's individual pregnancy needs or high elopement risks.

5. During an interview on 10/30/13 at approximately 3:00 PM, Staff NNN, Advanced Practice Registered Nurse and facility nurse Practice Specialist, stated that Patient #38 should have had a plan of care which addressed her individual pregnancy needs and elopement risks.

6. Observation on 10/29/13 at 3:10 PM in the Adult Psychiatric Unit showed Patient #39 sitting in the day room (a common area for all patients to gather) with a yellow isolation gown over his hospital gown and scrub pants.

7. During an interview on 10/29/13 at 3:10 PM, Patient #39 stated that he was told to wear the yellow gown over his clothes because he has an infection but doesn't know what it is or what has been done to get rid of it. He stated that he believes the yellow gown means "caution" and tells everyone to be careful around him so they don't catch his infection. He stated that he didn't know anything more about his infection but would like to know more.

8. Record review of Patient #39's medical record showed:
- The patient was admitted involuntarily on 10/27/13.
- He was diagnosed with methicillin-resistant staphylococcus aureus (MRSA, a bacteria resistant to the antibiotic methicillin, spread from person to person or through environmental contact.)
- No plan of care developed for the patient's individual needs related to the MRSA infection or isolation precautions.

9. Observation on 10/29/13 at 3:30 PM in the Intensive Care Psychiatric Unit (ICU) showed Patient #40 walking in the hallway outside of his assigned room wearing a yellow isolation gown over his hospital gown and scrub pants. A sign which read "contact isolation" was posted outside his room.

10. During an interview on 10/29/13 at 3:30 PM, Patient #40 stated that:
- No one had provided information/education about his infection.
- He was not aware of when or if he could stop wearing the isolation gown.
- Plans for getting rid of the infection such as taking medicine or more testing had not been discussed with him.

11. Record review of Patient #40's medical record showed:
- The patient was admitted on 10/27/13.
- He was diagnosed with an infection of Vancomycin-Resistant Enterococci (VRE, a type of bacteria that have developed a resistance to many antibiotics especially Vancomycin, spread from person to person or through environmental contact.)
- No plan of care was developed for the patient's individual needs related to the VRE infection or isolation precautions.

12. During an interview on 10/29/13 Staff VV, RN, stated that Patient #40 should have had a care plan which identified his individual needs based on his infection and isolation precautions.

13. Record review of Patient #54's medical record showed:
- She was admitted on 10/10/13 to the ICU from the facility Emergency Department (ED).
- She was brought to the ED with complaints of "vaginal pain"
- Was assessed as uncooperative and delusional (not thinking clearly, false thinking and beliefs).
- A pelvic examination showed skin tears on her right and left inner thighs, vaginal discharge containing pus (yellowish or greenish fluid that forms at sites of infection, consisting of dead white blood cells, dead tissue, bacteria, and blood serum), and friable (broken down) vaginal tissue.
- She had severe abdominal pain upon physical examination.
-The patient was diagnosed with Pelvic Inflammatory Disease (PID, inflammation of the female reproductive organs usually caused by sexually transmitted diseases.)
- Antibiotics were administered intravenously while in the ED.
- A physician order was written for continued antibiotic therapy after she was admitted to the ICU psychiatric unit.
- There was no care plan developed based on the patient's individual assessment and PID infection.

14. Observation on 10/30/13 at 3:45 PM in the ICU showed Patient #79 pacing (walking back and forth) in the hallway prior to being seated in a chair in the activity room. His hands were trembling, had a flushed (reddish color) appearance to the skin on his head and neck and his facial expressions were tense.

15. During an interview on 10/30/13 at 3:45 PM, Patient #79 stated that he had been drunk and high on heroin, cocaine or any drug he could get for 40 years and he was addicted and going through a "hard time toughing it out" with cravings for drugs and alcohol and feeling awful. He stated that he was not aware of any special precautions, treatments or medicines to monitor the withdrawals or control his cravings.

16. Record review of Patient #79's medical record showed:
- He was admitted involuntarily on 10/25/13 for acute drug and alcohol dependence.
- He had a long standing history of severe, extensive, illegal drug and alcohol abuse/dependence.
- No plan of care for the patient's potential or actual drug and alcohol dependence withdrawal.

17. During an interview on 10/30/13 at 10:15 AM Staff Staff FFF, Infection Control Manager, stated that patients who have been identified with infections, including VRE or MRSA, should have had care plans developed that address the patient's individual needs.

18. During an interview on 10/30/13 at approximately 3:30 PM Staff NNN, and Staff VV, stated that patients who have needs identified related to infection, pregnancy and substance addiction with potential withdrawal should have an individualized care plan with goals, approaches to care and expected outcomes based on their individual needs.