HospitalInspections.org

Based on a review of documentation, the facility failed to appoint a chief executive officer responsible for managing the hospital.

Findings were:

Based on a review of the clinical records for 10 patients:

Facility policy 900.50 titled "Suicide Risk Assessment" states, in part:
"Procedure:
A suicide risk assessment will be completed by the Admissions Coordinator as part of the initial comprehensive assessment or pre-admission screening.
...
Risk Level of 45 or Higher:
-Notify Charge Nurse
-Notify Attending Practitioner
-Treatment Plan
-Reassess risk level within 48 hours (SRA)"

1 of 10 patients (patient #2) scored "High" on a Suicide Risk Assessment, but the record contained no documentation that the charge nurse was notified, the attending practitioner was notified or that the findings were incorporated into the patient's treatment plan.

Facility policy 1000.77 titled "Treatment Planning" states, in part:
"Policy: An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to Cedar Crest. The Treatment Plan will be initiated, reviewed and updated by the interdisciplinary Treatment Tearm with patient and parent/guardian/family member participation (as appropriate) on a regular basis during the course of treatment.

Definitions:
Master Treatment Plan (MTP) - Is interdisciplinary in nature and shall be completed for the different levels of care as follow(sic):
Acute Care: 72 hours

Treatment Plan Review (TPR) - The interdisciplinary document is used to track & report the patient's progress toward treatment goals and shall be completed as follow(sic):
Acute care: No later than every 7 days

Interdisciplinary Treatment Team - The interdisciplinary treatment team members include but are not limited to: psychiatrist/nurse practitioner, psychiatric nurse, case manager/recreational therapy (RT) staff, the patient, the patient's parent/guardian/family member (if appropriate and/or consented), and in accordance with the law and regulation (if a minor) other support staff as need is identified.

4 of 10 patients (patients #2, #5, #7 and #10) did not receive treatment planning services in accordance with facility policy.
-Patient #2 was admitted on 3-8-17 and discharged on 3-23-17. Only 1 treatment team meeting was held during the patient's stay (on 3-10-17) and neither social services nor the patient participated in the meeting).
-Patient #5 was admitted on 3-6-17 and discharged on 3-10-17. A treatment team meeting was held on 3-7-17, but no physician or nurse participated in the meeting. The patient signed the form to indicate attendance & participation, but the signature was dated 3-9-17.
-Patient #7 was admitted on 3-9-17 and dicharged on 3-19-17. Only 1 treatment team meeting was held during the patient's stay (on 3-10-17).
-Patient #10 was admitted on 3-10-17 and discharged on 6-13-17. Treatment team meetings were held only on 3-13-17, 3-23-17, 3-31-17, 4-7-17, 4-21-17, 4-28-17, 5-10-17, 5-30-17 and 6-6-17.

Facility policy 100.86 titled "Discharge Planning" states, in part:
"Procedure:
6. Clinical/Nursing Staff proceed with discharge planning activities as ordered by the attending physician in a timely manner. Discharge planning activities are identified as follow(sic):
6.2 Nursing staff will be responsible for reviewing all discharge medications ordered by the physician as well as providing the patient and parent/guardian/family with a list of current medications. The RN will compete, review, and provide medication teaching to the patient/family/guardian/other designated individuals, obtain signatures, and provide a copy to the family."

2 of 10 patient records (patients #2 and #4) contained no patient/parent/guardian/family signature on the "Discharge Orders & Instructions" form, which would acknowledge understanding of all discharge orders and instructions provided.

Facility policy 1000.87 titled "Discharge of Patients (Routine, AMAs, 15-30 day request for Transfer)" states, in part:
"Procedure:
1. The physician competes and signs the Discharge Orders/Instructions Form and the Clinical Case Manger completes the Aftercare Appointments section, whenever possible. All patients are to be assessed by a physician on the day of discharge."

2 of 10 patient records (patients #3 & #7) contained no documentation that the patient was seen by the physician on the day of discharge.
-Patient #3 discharged on 3-19-17 but contained no documentation of a physician visit after 3-18-17.
-Patient 37 discharged on 3-19-17 but contained no documentation of a physician visit after 3-18-17.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 7-18-17.