HospitalInspections.org

42351

Based on interview and record review, the facility failed to provide a safe setting by not appropriately communicating in writing with dietary kitchen staff the food allergies of 2 of 2 patients. This failed practice has the potential to cause harm to patients with food allergies.

The findings are:

A. On 10/20/2020 at 9:25 am during interview, S#7 confirmed meal selections (diet sheets used to select meals for breakfast, lunch, and dinner) are faxed to dietary kitchen staff on the evening before indicating what patient selected for each meal for the following day. If a patient has allergies, it is indicated on the diet sheet.

B. On 10/20/2020 at 9:30 am during interview, S#12 confirmed diet sheet for P#4 was faxed the evening before for meal selections for 10/20/2020 and there was no indication patient had allergies to peanuts.

C. Record review of P#4's Nutrition Consultation Report dated 10/13/2020 at 12:16 revealed allergy to peanuts.

D. Record Review of P#4's diet sheets dated 10/16/2020 - 10/20/2020 revealed, under the food allergies column, no indication P#4 has allergy to peanuts.

E. Record review of P#1's Nutrition Consultation Report dated 07/09/2020 at 9:39 am, revealed allergies peanuts and dairy.

F. Record review of P#1's Diet Sheets dated 07/07/2020- 07/13/2020, revealed food allergies almond milk w/meals/NO green Chile and no indication of peanut allergy.

Based on record review and interview, the facility failed to have a program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases specific to health and safety of patients receiving care in the hospital setting. There was no Tuberculosis (TB) testing, (skin test that determines if you have tuberculosis which is a serious infection, usually of the lungs caused by the bacteria, Mycobacterium tuberculosis, and is spread when you breathe in the air exhaled by a person infected with tuberculosis) conducted yearly for 4 of 4 staff records reviewed. This deficient practice could result in the spread of communicable organisms (diseases) to patients.

The findings are:

A. Record review of S#16, S#18 & S#19, staff files revealed no evidence of annual TB screening. S#20 had a chest x-ray dated 5/16/2017 with no Annual Risk Assessment conducted.

B. On 10/20/2020 at 3:30 PM during interview, S#21(Human Resources) confirmed that TB is completed at hire, annually and after any known exposures to TB. S#21 confirmed that the facility is in the process of trying to get all staff TB screenings completed in the same month and should be complete and up to date by 10/31/2020.

C. Record review of facility policy titled "TB Prevention Program ", dated 06/2020, reveals "b. TB testing is mandatory for all employees upon hire. Annual TB testing or assessment is required for direct patient contact staff as required by state law", and "b.1. "Annual employee TB Risk Assessment Questionnaire will be completed for those employees unable to have an annual TB skin test, or if state law allows for annual assessment only".

Based on interview, observation, and record review, the facility failed to meet the Condition of Participation (CoP) for Special Medical Record Requirements by failing to maintain medical records to determine the degree and intensity of the treatment provided to patients in the facility as evidenced by the following:


A. The facility failed to provide psychosocial assessments that met professional social work standards. See tag 1625.

B. The facility failed to provide a psychiatric evaluation that included individualized personal assets on which to base a meaningful treatment plan for 4 of 10 records reviewed (P1, P5, P6, P8). See tag 1637.

C. The facility failed to develop treatment plans that are individualized based on the patient's strengths and disabilities. See tag 1640.

D. The facility failed to document active treatment involving ongoing assessment, diagnosis, intervention, evaluation of care and treatment. See tag 1650.

42472

Based on record review and interviews, the facility failed to provide psychosocial assessments that met professional social work standards. These assessments failed to include conclusions and recommendations that described anticipated social work roles in inpatient treatment and discharge planning for 8 of 10 patients sampled (P1, P4, P5, P6, P7, P8, P9, and P10). This deficient practice is likely to result in a lack of professional social work treatment services and/or lack of input to the treatment team to assist in the care of the patient during hospitalization.

Findings are:

A. Record review of P1's Psychosocial Evaluation, dated 07/08/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"Pt. should attend groups and receive psycho education for substance abuse, triggers, stressors and coping skills."

B. Record review of P4's Psychosocial Evaluation, dated 10/13/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"Med management with Dr. [unreadable name] and counseling through Laguna Behavioral Health."

C. Record review of P5's Psychosocial Evaluation, dated 10/03/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"Encourage medication and treatment compliance. Encourage group participation. 1:1 social services clinician."

D. Record review of P6's Psychosocial Evaluation, dated 10/13/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"Address TX. [SIC] Goal and coordinate aftercare services."

E. Record review of P7's Psychosocial Evaluation, dated 10/15/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"1:1 Social Services Clinician. Encourage group participation. Encourage treatment and medication compliance."

F. Record review of P8's Psychosocial Evaluation, dated 09/28/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"address psychosis and SA [SIC] with [unreadable word], medical, 4 [SIC] psychotic intervention. Coordinate with discharge for aftercare."

G. Record review of P9's Psychosocial Evaluation, dated 10/14/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"[patient name] will work with the clinical team to address TX [SIC] goals and to coordinate aftercare services."

H. Record review of P10's Psychosocial Evaluation, dated 10/09/2020, listed the following generic non- individualized social work inpatient recommendations for treatment:
"[patient name] will address TX [SIC] goals through clinical, therapeutic, and medical [unreadable word]. [pt. name] will [unreadable word] aftercare services and placement coordinated with [unreadable word]."

I. On 10/21/20 at 4:05 pm during interview S3 (Director of Social Services) revealed, "the treatment plan recommendations on the psychosocial evaluation did not explain what the social worker was doing to address social work interventions with the patient during their (the patient's) hospitalization."

42472

Based on record review and interview, the facility failed to provide a psychiatric evaluation that included individualized personal assets on which to base a meaningful treatment plan for 4 of 10 records reviewed (P1, P5, P6, P8). This deficient practice is likely to not identify patient strengths and has the potential to impair the treatment team's ability to choose treatment modalities which best utilize the patient's attributes in therapy.

Findings are:
A. Record review of P1's Psychiatric Evaluation, dated 07/08/20, reveals the non-individualized assets: "Strengths: Taking care of family."

B. Record review of P5's Psychiatric Evaluation, dated 10/02/20, listed the non-individualized assets: "Somewhat poor, as patient is semi-uncooperative with interviews in ER and here. Patient is with psychosocial stressors. She is unable to specify any strengths or weaknesses."

C. Record review of P6's Psychiatric Evaluation, dated 10/13/20, listed the non-individualized assets: "Poor, as patient is not med [SIC] compliant and has a hx [SIC] of hospitalizations. Patient states that her strengths are music and writing, but that her weaknesses are anger and confrontation."

D. Record review of P8's Psychiatric Evaluation, dated 09/27/20, listed the non-individualized assets: "refused to answer."

E. On 10/20/20 at 11:00 a.m. during interview S1 (CEO/Acting Director of Nursing) confirmed, that assets on the psychiatric evaluation should not be only what the patient thinks are strengths but rather based on the information the provider gathers prior to and during the assessment.

42472

Based on record review, interview and observation the facility failed to develop treatment plans that are individualized based on the patient's strengths and disabilities. This deficient practice is likely to develop treatment plans that are not effective.

Findings are:

A. Record review of 4 (P4, P6, P8, P9) of 10 patients (pts.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Psychotic Behaviors" as problem #1 was identical wording for the first heading under "Short Term Goals". This identical wording occurred in the MMTP's of P4 (dated 10/13/20), P6 (dated 10/13/20), P8 (dated 9/28/20) and P9 (dated 10/14/20):
"(Pt. name) will work with Facility psychiatric provider to learn about psychotic symptoms and diagnosis and learn ways to reduce symptoms."

B. Record review of 4 (P4, P6, P8, P9) of 10 patients (pts.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Psychotic Behaviors" as problem #1 was identical wording for the second heading under "Short Term Goals". This identical wording occurred in the MMTP's of P4 (dated 10/13/20), P6 (dated 10/13/20), P8 (dated 9/28/20) and P9 (dated 10/14/20):
"(Pt. name) will learn how medication helps address psychosis and the need to be observant of side effects."

C. Record review of 4 (P4, P6, P8, P9) of 10 patients (pts.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Psychotic Behaviors" as problem #1 was identical wording for the third heading under "Short Term Goals". This identical wording occurred in the MMTP's of P4 (dated 10/13/20), P6 (dated 10/13/20), P8 (dated 9/28/20) and P9 (dated 10/14/20):
"(Pt. name) will work with nursing staff engaging in Facility programing including rounding, treatment engagement and participation in ADL's (Activities of dail living - daily self-care activities) including bathing, eating, toileting, sleeping as well as engaging with peers and staff."

D. Record review of 4 (P4, P6, P8, P9) of 10 patient (pt.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Psychotic Behaviors" as problem #1 was identical wording for the first heading under "Multidisciplinary Interventions- Type/Modality". This identical wording occurred in the MMTP's of P4 (dated 10/13/20), P6 (dated 10/13/20), P8 (dated 9/28/20) and P9 (dated 10/14/20):
"Assess level of psychosis and mental status, presence of internal stimuli, mood and SI/HI as well as effectiveness of medication."

E. Record review of 4 (P4, P6, P8, P9) of 10 patient (pt.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Psychotic Behaviors" as problem #1 was identical wording for the second heading under "Multidisciplinary Interventions- Type/Modality". This identical wording occurred in the MMTP's of P4 (dated 10/13/20), P6 (dated 10/13/20), P8 (dated 9/28/20) and P9 (dated 10/14/20):
"Educate on side effects and need to engage in skills as well as medication management."

F. Record review of 4 (P4, P6, P8, P9) of 10 patient (pt.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Psychotic Behaviors" as problem #1 was identical wording for the third heading under "Multidisciplinary Interventions- Type/Modality". This identical wording occurred in the MMTP's of P4 (dated 10/13/20), P6 (dated 10/13/20), P8 (dated 9/28/20) and P9 (dated 10/14/20):
"Treat psychosis."

G. Record review of 4 (P1, P5, P7, P10) of 10 patients (pts.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Depressed Mood" or "Depressed Mood/SI" as problem #1 was identical wording for the first heading under "Short Term Goals". This identical wording occurred in the MMTP's of P1 (dated 7/09/20), P5 (dated 10/04/20), P7 (dated 10/16/20) and P10 (dated 10/09/20):
"(Pt. name) will work with Facility psychiatric provider to learn about depression and ways to reduce symptoms."

H. Record review of 4 (P1, P5, P7, P10) of 10 patients (pts.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Depressed Mood" or "Depressed Mood/SI" as problem #1 was identical wording for the second heading under "Short Term Goals". This identical wording occurred in the MMTP's of P1 (dated 7/09/20), P5 (dated 10/04/20), P7 (dated 10/16/20) and P10 (dated 10/09/20):
"(Pt. name) will learn how medication helps address depression and the need to be observant of side effects.

I. Record review of 4 (P1, P5, P7, P10) of 10 patients (pts.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Depressed Mood" or "Depressed Mood/SI" as problem #1 was identical wording for the first heading under "Multidisciplinary Interventions- Type/Modality". This identical wording occurred in the MMTP's of P1 (dated 7/09/20), P5 (dated 10/04/20), P7 (dated 10/16/20) and P10 (dated 10/09/20):
"Assess level of mood and mental status, presence of internal stimuli and SI/HI as well as effectiveness of medication."

J. Record review of 4 (P1, P5, P7, P10) of 10 patients (pts.) "Multidisciplinary Master Treatment Plans" (MMTP's) revealed that listed under "Depressed Mood" or "Depressed Mood/SI" as problem #1 was identical wording for the second heading under "Multidisciplinary Interventions- Type/Modality". This identical wording occurred in the MMTP's of P1 (dated 7/09/20), P5 (dated 10/04/20), P7 (dated 10/16/20) and P10 (dated 10/09/20):
"Educate on side effects and need to engage in skills as well as medication management."

K. Record review of the facility's "Treatment Plan, PolicyStat ID: 8073414, Last Approved 05/2020" revealed the following statements:
1. "Purpose: To provide a process and guidelines for implementation of comprehensive, individualized treatment planning for every patient."
2. "Multidisciplinary Treatment Plan: H. The interventions shall be highly individualized, reasonable and necessary to improve the condition that necessitated the hospitalization. Such interventions from the basis of 'Active Treatment'."

L. On 10/19/20 at 12:20 pm during interview with S3 (Director of Social Work), she stated that the Activity Therapy (AT) staff pushed carts to the patients in their rooms and offered leisure activity sheets such as "word search," "connect the dots," and other worksheets and reading material. S3 further stated that the social work staff continued their normal one-to-one therapeutic schedule with patients. S3 didn't know whether the Multidisciplinary Master Treatment Plans (MMTPs) had been modified to include any the current interactions by activity therapy staff.

M. On 10/20/20 at 11:00 am during interview with S1 (CEO), she agreed that the MMTPs were almost identical, cut and paste, and not individualized. S1 further verified that the shared interventions (on the MMTPs) were generic and not specific to individual patient needs.

42472

Based on record review, interview and observation the facility failed to document active treatment involving ongoing assessment, diagnosis, intervention, evaluation of care and treatment. This deficient practice is likely to not assure patients to achieve their optimal level of functioning.

Findings are:

A. Record review of P5's initial Multidisciplinary Master Treatment Plan (MMTP) dated 10/4/20: "(Pt. name) will work with nursing staff engaging in Facility Programing including rounding, treatment engagement and participation in ADL's (Activities of Daily Living- Basic personal needs such as eating, drinking fluids, personal hygiene, etc.) including bathing, eating, toileting, sleeping as well as engaging with peers and staff."

B. Record review of P5's Multidisciplinary Master Treatment Plan (MMTP) Update dated 10/11/20: "(Pt. name) has made no progress on this goal she does not get out of bed, she sleeps, and she does not eat at all." The only "Changes/Revisions to Treatment Plan" listed are: "Court was filed for a treatment guardian and commitment for (Pt. name)."

C. Record review of P5's Multidisciplinary Master Treatment Plan (MMTP) Update dated 10/18/20: "(Pt. name) has made no progress on this goal she does not get out of bed, she sleeps, and she does not eat at all." The only "Changes/Revisions to Treatment Plan" listed are: "Treatment guardian and commitment granted for (Pt. name). Will need to wait for Facility availability."

D. Record review of P5's progress note on 10/05/20: "Patient is found lying in bed. She has been sleeping ...eating poorly. She has missed breakfast again and did not eat dinner last night. Patient is not attending any groups."

E. Record review of P5's progress note on 10/07/20: "Patient refuses to participate in her own care. Patient isolates to her room and stays in her bed most of the time. She continues to refuse meals. Patient is not attending groups."

F. Record review of P5's progress note on 10/10/20: "Patient continues to refuse interview, by either playing possum or ignoring the providers. She continues to refuse meals and her Boosts. Patient is not attending groups."

G. Record review of P5's progress note on 10/12/20: "She continues to not be responsive to interview. She will often respond to eternal rubs ... is not attending any groups. She continues to refuse meals and her Boosts."

H. Record review of P5's progress note on 10/15/20: "Patient continues to refuse interview ...continues to refuse meals and Boosts. She does drink water. Patient is not attending any groups."

I. Record review of P5's progress note on 10/19/20: "As patient is un-willing to participate in all ADLs, including drinking water to the point that the provider is concerned that patient is dangerously dehydrated and currently has a UTI (Urinary tract infection - a bladder infection). Therefore, patient will be transferred at 4pm this evening via non-emergency ambulance to Facility ER, ..."

J. Record review of P5's progress note on 10/20/10: "Patient had went to Facility ER last night where she received a Liter of saline IV (Replacement fluid to treat or prevent dehydration that is administrered directly into a patients' blood stream) and then was transferred back here. When provider interview, she had rolled over and had refused interview. She has refused all meals and water. Patient is not attending any groups."

K. On 10/20/20 at 11:15 am during interview with S16 (MD, Medical Director- Also present were S3, Director of Social Work; and S17, Nurse Manager), surveyor asked S16 about the care of Patient P5 and he responded that the patient was a difficult patient, wouldn't take medication by mouth, wouldn't communicate with him, and wouldn't eat food or drink boost but would drink some water. He further stated the patient was mostly mute and had attended none of the groups assigned since admission. He voiced that ECT (Electro Convulsive Therapy- A psychiatric treatment modality) might be helpful but that the only provider who offered it locally was booked for months. The patient had been placed on a list for transfer to the Facility, but S16 thought it would take a while to get a bed there and didn't think they provided ECT. When asked what the state hospital would provide for Patient P5 that the staff at the Facility couldn't provide, the Medical Director said that he wasn't sure. When asked if he had requested consultation with other professionals to develop a plan of care, he stated that he had talked with some of his colleagues, but they didn't give any suggestions for treatment. The group did not respond when asked why these problems were not addressed on the MTP but stated that they had talked about the problems in the treatment team meetings and had concerns about the lack of progress the patient was making. The group did not seem to know that the patient had not showered or received oral care since admission.

L. On 10/20/20 at 1:50 pm observation of the patient area revealed, P5 was in bed with the door closed. surveyors knocked and entered her room. She was in bed with eyes closed. P5 did not respond to her name being called several times but did roll over in the bed away from surveyors. A closed lunch tray and milk carton was on the bedside table--tray had not been opened and the carton was full and unopened.

M. On 10/20/20 at 1:55 pm during interview with S22 (BHT), he stated that patient P5 stayed in her bed almost all the time and he had never seen her eat solid food. When asked about hygiene activities such as taking showers and brushing teeth, S22 stated that he did not think that P5 had showered or brushed her teeth since admission. BHT stated that staff put a 32 ounce cup of water on the bedside table each day and that Patient P5 usually drank about half (16) ounces a day. When asked if Patient P5 ever talked, he stated that she would mostly ignore staff and if she did talk it was to tell them to get out of the room. S22 said that patient was responsive about 50% of the time to "procedures, like taking her vital signs and temperature, or getting her weight."

N. On 10/20/20 at 2:00 pm during interview with S7 (RN Charge Nurse), she stated that she was aware of only one time that Patient P5 had taken a shower and brushed her teeth since admission on 10/01/20. S7 further stated that the patient had never attended group, was mute most of the time, stayed in bed almost all day, and did not eat food or drink Boost (a nutritional supplement) but would drink water.

O. On 10/19/10 at 11:35 a.m. observation on the patient area revealed that no groups were listed for the day on the programming chalk board. The census on the unit was six patients. One patient was sitting at the end of hallway and the other five patients were in their rooms in bed.

P. On 10/19/20 at 12:15 p.m. during interview with S1 (CEO), she stated that she had been mistaken when saying earlier that groups had resumed on the Unit. S1 stated that the Social Work Director had not been told to resume groups, so the schedule had not been posted and the 9:30 a.m. group had not been facilitated. She stated that groups had now resumed.

R. On 10/19/20 at 2:10 p.m. observation on the patient area revealed that a social work group on Anger Management was being held. The census on the unit was six patients. There were three patients in the group and the other three patients were in bed.

S. On 10/19/20 at 2:20 p.m. during interview with S17 (Nurse Manager), we asked how the staff encourage patients to go to groups, she replied that the staff knock on the patients' doors and tell them that group is starting. She further stated that if the patient didn't want to go to group, the staff did nothing because the patients were "allowed not to go".

T. On 10/20/20 at 10:00 a.m. observation of the patient area revealed Activities Group was in progress. The census on the unit was now nine patients. There were three patients in the group. The remaining six patients were in their rooms.

W. On 10/20/10 at 10:10 a.m. during interview S22 (RN), when asked what staff do when patients refuse groups stated, "We can't make them go to group. If they are asleep, we don't wake them up."

X. On 10/20/20 at 2:10 p.m. observation on the patient area revealed that a social work group was in progress. The census on the unit was now 11 patients. Five of the 11 patients were in the group. Six of the patients were in their beds.