HospitalInspections.org

Based on a review of medical records and interview with administrative staff it was determined the facility failed to include the patient or family in the development of an individualized treatment care plan to meet their needs.
This had the potential to affect all patients served by the facility and did affect Medical Record (MR) # 6.

Findings include:

MR # 6 was admitted on 5/29/12 to the adult psychiatric unit with Axis I diagnosis of Schizophrenia and Axis III diagnoses including Deafness and Mute, Mental Retardation and Seizures.

A review of the Hospital Treatment Plan, dated 6/01/12, included, "Criteria for discharge (long term goal): ...will exhibit a decrease in Hallucinations and unstable mood. Consumer strengths/assets which facilitate achievement of treatment goals: Good physical health, support of family and friend. Liabilities/weakness and special needs-possible barriers to treatment: Hearing, Legal issues, Medication non-compliance and Speech.

The master problems included Hallucinations and Medication Non-compliance. The plan did not include documentation of this patient's hearing impairment or how this might affect participation in attending group activities and interaction with staff on the unit.

An interview on 6/07/12 at 10:05 AM with Employee Identifier (EI) # 1, Director of Performance Improvement, confirmed the above.


Refer to B 118.

Based on observations and interviews it was determined the facility failed to ensure the patients were in a safe environment. This had the potential to negatively affect all patients being served by this facility.

Findings include:

During an intial tour conducted on 6/5/12 at 10:50 AM the surveyor noted the following on the children and adolescent girls unit:

Room 610 - piece of sharp metal sticking away from air conditioner approximately 2 cm (centimeters) and a chicken leg bone.


Room 612 - a piece of the metal window frame was pulled away allowing 4 cm of metal with a very sharp edge exposed.


Room 614 - the edge of the window frame was without a screw and allowed for fingers to pull the piece of metal away from the frame to expose a very sharped edge.


An interview was conducted with Employee Identifer (EI) # 2, the Hospital Administrator on 6/5/12 at 11:00 AM who verified the above and stated they should not have the sharped edges.


During a tour on 6/5/12 at 11:10 AM on the adolescent boys unit the surveyor noted 6 sharpened pencils laying on a table in the day room. The surveyor asked EI # 2 if the pencils should be readily available for the patients to use and the response from, "absolutely not."




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During an intial tour conducted on 6/5/12 at 11:00 AM the surveyor noted:

Room 412- writing on the wall in the bathroom, the fire alarm box pulled off of the wall in the bathroom had been stuck back on the wall which was a hazard if removed again by a patient and writing on the wall to the right of the door.


Room 414- the shower curtain in the bathroom only had two tabs left holding the curtain onto the shower rod. The plastic molding around the head of the bed frame had been pulled off allowing loose molding as a potential hazard.



08538

During a tour on 6/5/12 at 10:35 AM of the Dietary Department by the surveyor and Employee Identifier (EI) # 1, Director of Performance Improvement, the walk in freezer floor was observed with ice accumulation making it very slippery and a potential hazard for falls.

Based on review of medical records, review of policy and procedures and interview it was determined the facility failed to:
1. Follow facility policy and procedures for time out.
2. Follow facility policy and procedure for restraint and seclusion.
3. Have completed documentation on the restraint and seclusion forms.

This had the potential to affect all consumers in the facility. This did affect Medical Record (MR) # 1, # 3 and # 4.

Agency Policy # TX 4.2
Use of Seclusion & Restraint
Revised: 6/2/11

Policy:
The use of seclusion (the placement of a consumer alone in any room, from which the consumer is physically prevented from leaving, for any period of time) and/or restraint (the direct application of physical force to an individual served with or without the consumer's permission to restrict the consumer's freedom of movement by utilizing MindSet Techniques and Principals), may be implemented only in an emergency as a safety measure for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the consumer, staff members or others.


Procedure:
2. Staff will first attempt to prevent emergencies using communication skills to deescalate the situation following MindSet guidelines...
3. Staffing levels will be determined by the level of severity of consumers for the particular program in order to maximize safety and minimize seclusion and restraint. Census and population will be considered to minimize circumstances leading to seclusion and restraint..
4. Seclusion/restraint may be initiated only by order of a licensed independent practitioner (LIP) who is primarily responsible for the individual's care...
6. Orders for initial and continuing use of restraint and seclusion have the following characteristics:
are limited to 1 hour for children and adolescents ages;
18... For children/ adolescent consumers, per DHR (Department of Human Resources) requirements, the family and DHR worker shall be notified, within 24 hours, if the consumer is placed in seclusion/restraint 3 times or more in a 24 hour period or for more than 2 hours in a 24 hour period. The treatment team and program director will review the appropriateness of seclusion/restraint and the need for alternative interventions.

Agency Policy: Use of Room Restriction/ Time-Out
Policy:
When a consumer is unable to function within the structure of the program, Room Restriction and Time Out are used to give the consumer a safe environment to calm down and consider the consequence of his/her behavior.

Procedure:Room restriction and Time Out should be used to assist consumers in regaining self control. With any undesirable behavior, the lowest step of verbalization is desirable in order to help the consumer make the appropriate choices. All directions should be given calmly and with respect, utilizing MindSet principles.
... In the event of extreme acting out (hurting self or someone else, destroying property, running away), it is not necessary to follow each step in succession...

I. Time Out
A consumer in time out must never be physically prevented from leaving the time out area. Time out may take place away from the area of activity or from other consumers such as in the consumer's room (exclusion area) or in the area of activity of other consumers (inclusion area).

Staff must monitor the consumer while he or she is in time out. Documentation shall support that these procedures are followed and shall include the following:
The circumstances that lead to the use of time out regardless of whether the time out was consumer requested, staff suggested or staff directed.
Name and credentials of staff who monitored the consumer throughout the timeout.
Where on the provider's premises either an inclusionary or an exclusionary timeout was implemented.
The length of time for which timeout was implemented. Behavioral or other criteria for release from time out if applicable.
The status of time out when timeout ended.


Medical Record (MR) Findings:


1. MR # 4 was admitted to the facility on 4/27/12 with Axis I diagnoses of Major depressive Disorder, Oppositional Defiant Disorder, ADHD (Attention Deficit Hyperactivity Disorder) combined type; Parent-Child Relational Problems.

On 4/30/12 at 8:00 AM, the nursing progress note documented, " Consumer sent to time out staff will continue to monitor for any problems."

The physician documented at 8:15 AM, " Pt (patient) got into physical altercation with another consumer, cons (consumer) admits to punching him, pt had to be restrained from almost hitting another pt."

There was no time out form completed on the patient for 4/30/12.

On 5/1/12 at 3:55 PM, the nursing progress note documented, " Consumer placed in time out, cons hanging on door repeatedly cursing, cons medicated with Benadryl 50 mg ( milligrams) IM (intramuscular) time 1."

On 5/1/12 at 4:10 PM, the nursing progress note documented, " Consumer... in seclusion... continue to monitor."

On 5/1/12 at 2:55 PM, the Seclusion/ Restraint placement form documented MR # 4 was placed in seclusion for 5 minutes.

On 5/1/12 at 3:00 PM, the Seclusion/ Restraint placement form documented MR # 4 was placed in restraint for 20 minutes. The form was not completed to show if the type of restraint was a physical hold or mechanical restraint.

The 15 minute precaution record completed by the Behavioral Aide on 5/1/12, failed to document the patient was in restraint, seclusion or time out.

The nurses progress note documented 5/2/12 at 8:15 PM, " Cons put in restraint/seclusion, after running to room, retrieving pencil and attempting to re-enter day area after peer again."

On 5/2/12 at 8:29 PM, the Seclusion/ Restraint placement form documented MR # 4 was placed in restraint for 1 minute and seclusion for 30 minutes. The patient was medicated with Benadryl 50 mg by mouth.

The nurses progress not documented on 5/2/12 at 9:00 PM , " Released from seclusion. C/O (complaint) pain to right upper extremity. Area assessed by RN (registered nurse) skin broken/scratched in area of bite... cleaned with SNS ( sterile normal saline) and sterile gauze."


The 15 minute precaution record completed by the Behavioral Aide on 5/2/12, failed to document the patient was in restraint and/or seclusion.

In an interview on 6/7/12 at 11:10 AM with Employee Identifier (EI) # 1, the Director of Performance Improvement she confirmed the above information.


2. MR # 3 was discharged from Baypointe hospital 5/7/12 and re-admitted 5/10/12.


MR # 3 was admitted on 5/10/12 with Axis I diagnoses of Major depressive Disorder, Oppositional Defiant Disorder,Intermittent Explosive Disorder, ADHD (Attention Deficit Hyperactivity Disorder) combined type; Parent-Child Relational Problems.


On 5/10/12 at 5:50 PM, the Seclusion/ Restraint placement form documented MR # 3 was placed in Physical Hold for 5 minutes. The form failed to have the nurses signature on the second column of the form which had been tagged to show the form was incomplete. MR # 3 was medicated with Benadryl 50 mg intramuscularly.

On 5/11/12 at 10:30 AM, the Seclusion/ Restraint placement form documented MR # 3 was placed in restraint for 30 minutes. The form was not completed to show if the type of restraint was a physical hold or mechanical restraint. MR # 3 was medicated with Benadryl 50 mg IM.

The 15 minute precaution record completed on 5/11/12 by the behavioral aide, failed to document the patient was in restraint from 10:30 until 11:00 AM.

The patient was placed in restraint a second time 5/11/12 at 4:30 PM and medicated with Benadryl 25 mg IM, Ativan 1 mg IM, and Haldol 2 mg IM.
The form was not completed to show if the type of restraint was a physical hold or mechanical restraint.

The 15 minute record completed on MR # 3 failed to document the patient was in restraint from 4:30 until 5:00 PM.

On 5/12/12 at 8:50 AM, the Seclusion/ Restraint placement form documented MR # 3 in placed in Physical Hold for 5 minutes. The form also documented the patient was in seclusion from 8:55 AM until 9:20 AM for a total of 25 minutes. The patient was medicated with 25 mg of Benadryl by mouth.

The physician's order on 5/12/12 at 8:50 documented, " Restraint imminent threat to self, self injurious behavior. Order Guidelines: Restraint is limited to 1 hour for children and adolescents ages 9 -17, 1 hour for children under 6, 1 hour for adults ages 18 and over."

There was no physician's order for seclusion on 5/12/12.

On 5/18/12 at 10:28 AM, the Seclusion/ Restraint placement form documented total time in restraint 2 minutes. The form was not completed to show if the type of restraint was a physical hold or mechanical restraint.

The physician's order on 5/18/12 at 11:03 AM documented, " Restraint other: Elopement. Order Guidelines: Restraint is limited to 1 hour for children and adolescents ages 9 -17, 1 hour for children under 6, 1 hour for adults ages 18 and over."

In an interview on 6/7/12 at 11:00 AM with EI # 1, the Director of Performance Improvement confirmed the above information.

3. MR # 1 was admitted to the facility on 5/25/12 with Axis I diagnoses of Major Depressive Disorder, Moderate without Psychotic features, Sexual Abuse of a Child, Victim Posttraumatic Stress Disorder, Chronic Parent-Child Relational Problems, Child-Sibling Relational Problems, Learning Disorder, Not Otherwise Specified and Rule Out Reactive Attachment Disorder, Disinhibited Type.

The nursing progress note documented on 5/28/12 at 10:31 AM, " Kicking, screaming, defiant. Applied MindSet. Attempted distraction- unsuccessful, sent to time out, kicking wall in time out room."

There was no time out form completed on the patient for 5/28/12.

The nursing progress note documented on 5/28/12 at 4:38 PM , " Defiant refused to go to room to clean and rest, sent to time out, rocking bumping head against wall. Discourage behavior. He stopped shortly after."

There was no time out form completed on the patient for 5/28/12.

In an interview on 6/7/12 at 11:30 AM with EI # 1, the Director of Performance Improvement she confirmed the above information. EI # 1 provided to the surveyor a Time Out Progress Note form which was to be completed any time a consumer was placed in time out. EI # 1 stated that a form is suppose to be completed.

Based on record review and interview, it was determined the facility failed to ensure the staff documented a physician's order for restraint in 1 of 4 records reviewed with restraint/seclusion. This affected Medical Record # (MR) 3 and had the potential to affect all patients being served by this facility who were restrained/secluded.

Findings include:



18259

MR # 3 was discharged from Baypointe hospital 5/7/12 and re-admitted 5/10/12.


MR # 3 was admitted on 5/10/12 with Axis I diagnoses of Major depressive Disorder, Oppositional Defiant Disorder,Intermittent Explosive Disorder, ADHD (Attention Deficit Hyperactivity Disorder) combined type; Parent-Child Relational Problems.


On 5/11/12 at 10:30 AM, the Seclusion/ Restraint placement form documented MR # 3 was placed in restraint for 30 minutes. The form was not completed to show if the type of restraint was a physical hold or mechanical restraint. MR # 3 was medicated with Benadryl 50 mg IM.


There was no physician's order for the restraint on 5/11/12 at 10:30 AM.


The patient was placed in restraint a second time 5/11/12 at 4:30 PM and medicated with Benadryl 25 mg IM, Ativan 1 mg IM, and Haldol 2 mg IM.
The form was not completed to show if the type of restraint was a physical hold or mechanical restraint.


There was no physician's order for the restraint on 5/11/12 at 4:30 PM.

In an interview on 6/7/12 at 11:10 AM with Employee Identifier (EI) # 1, the Director of Performance Improvement she confirmed the above information.

Based on medical record review, hospital policies, standards of practice and interviews, the hospital nursing staff failed to document:

1. Physician orders for wound care.
2. The measurements of wounds identified.
3. An assessment of the wounds.
4. Care and treatments provided to wounds.
5. Physician orders for anti-psychotic medications.

This affected Medical Record (MR) #'s 10, 11 and 12 and had the potential to affect all patients with wounds and receiving anti-psychotic medications.

Findings include:

Chapter 610-x-6-.13
Alabama Board of Nursing Standards of Practice for Wound Care
(1) It is within the scope of a registered nurse or licensed practical nurse practice to perform wound care assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursant to an approved standardized procedure, outlined in Rule 610-x-6-.123, a Standardized Procedures, including supervised practical and demonstrated clinical competemce, initially and at periodic intervals.
(2) The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology
(c) Equipment and procedures used in wound assessment and care
(d) Chronic wound differentiation
(f) Measurement of wound
(g) Stage of wound
(h) Condition of wound bed
(i) Tissues
(ii) Exudate
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound
(j) Pain
(k) Complications, prevention and nursing intervention.


Policy # CTS 3.3.7 Subject: Wound Management and Dressing Changes

POLICY:
...Assessment and documentation of a wound include but is not limited to the following information:
Location of wound
Length/width/depth of wound
Wound base (pink, red, yellow, black or green)
Exudate (serous, bloody, purulent)
Odor
Sensation and pain

PROCEDURE: Wound Care Interventions:
1. Each consumer will be assessed for skin integrity at the time of admission.
2. A plan of care will be initiated as indicated.
3. Referrals will be made to appropriate facilities for wound care protocol.
4. The medical staff will address and manage underlying cause of wounds.
5. The medical staff will promote and adhere to infection control practices.
6. A pain assessment will be completed and referrals made to physician/CRNP's (Certified Registered Nurse Practioner) for effective management.
7. The medical staff will evaluate and document consumer's outcome.

1. MR # 12 was admitted to the adult psychiatric unit on 3/30/12 with Axis 1 diagnoses of Psychotic Disorder and Delirium. Axis III admission diagnoses included Diabetes Mellitus, Cellulitis, status post Stroke and Hypertension. This patient was discharged on 4/05/12.

A review of the nursing admission assessment, dated 3/30/12 at 1200 hours, included Integumentary status of lower extremities to include:
"(R) (right) great toe 1.5 x 1.5 wound
(L) (left) great toe upper 1.5 x 1 wound
(L) great toe lower 1 x 1.5 wound
(L) heel 4 x 5 x 0.5"

A review of a progress note, dated 3/30/12 at 2200 hours, included a head to toe assessment which included, "Cns (consumers) feet extremely raw; cns great toe on both feet appeared red and raw. 2230 hours Cns instruction for wound care left on chart; no order for wound care; will contact on call Dr. (doctor) for wound care consult and orders."

A review of the admission orders, dated 3/30/12, revealed no orders for wound care to the lower extremities.

A review of a Medical Consultation form, dated 3/30/12, included, "Please evaluate cons (consumer) wounds for wound care." A review of the Consult Evaluation, dated 4/2/12 (three days after admission) included, "Bilat (bilateral) wounds LE's (lower extremities). Has home health 3 x a week-clean with NS (normal saline) and apply dry dsg (dressing). Has WC (wound care) orders in progress here. Cont. (continue) current WC."

A review of the daily nurse progress notes from 3/31/12 to 4/5/12 revealed the following:

3/31/12 at 0530 "Cns bleeding (R) toe; washed with NS (normal saline) and applied clean sterile gauze dressing. 1000 Drsg (dressing) to bilateral feet intact." There was no documentation of wound care to the left foot wounds.

4/01/12 at 1500 "Dressing change to Bil (bilateral) feet completed. 2050 Cns bandages intact; dry. 2350 Cns at nurses station requesting bandage on (L) foot be re-taped." There was no documentation of specific wound care provided to the wounds on the right and left feet during this dressing change.

4/02/12 No documentation of wound care or assessment of bilateral feet.

4/03/12 at 1900 "Cleaned and dressed wounds on both feet. Dressing intact." There was no documentation of the specific wound care provided.

4/04/12 at 1855 "Changed bilateral lower ext (extremity) bandages. Medication applied to both feet and wrapped with Kerlex. Cns had + (plus) 4 edema on bilateral feet. States (left) heel hurts to touch. 2140 cns speaking about bandage on feet; cns complained that bandage was loose. 2150 cns bandage re-dressed..." There was no documentation of the type of medication applied to the bilateral feet. There was no physician's order for a medication to be applied to the feet or notification to the physician of the edema and pain.

4/05/12 at 0900 "Bandages intact on bilateral feet. Legs are swollen. Consumer c/o (complained) lower ext pain. Ask (asked) for pain meds." This patient was given Ibuprofen for pain, however, there was no documentation of wound care provided or further assessment of the wounds and swollen legs. The patient was discharged to a nursing home at 1745.

An interview on 6/07/12 at 10:15 AM with Employee Identifier (EI) # 1, Director of Performance Improvement and EI # 5, Hospital Administrator, confirmed the above findings.


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2. MR # 11 was admitted to the facility on 4/27/12 with Axis I diagnoses of Impulse Control Disorder, History of Factitious Disorder, History of Bipolar disorder, Benzodiazepine Dependence and History of Opoid Dependence. Axis III diagnosis of Status Post Abdominal Surgery.

The patient was received from an acute care hospital 4/27/12 after having surgery to remove a razor blade she had swallowed. The discharge instructions from the hospital documented under treatment, " keep wound vac( vacuum) in place. Dressing to abdominal incision to be changed on May 1st, 2012."

The admission orders included, " Highly aggressive, unpredictable behavior 1:1 routine and medical consult s/p ( status post) abdominal surgery with wound vac(vacuum)."

The nursing admission assessment completed 4/27/12 documented the following information:
Pain assessment- onset 2 days, left ear pain a 10 on a scale of 0-10.
Integumentary- surgical wound with staples- wound vacuum system.

There was no documentation of an assessment of the incision line, length, width, drainage, number of staples or measurement of the wound.

The medical consult form completed by the nurse 4/27/12 was to evaluate s/p abdominal surgery with abd( abdominal) wound vac also assess and treat for ear pain.

The nursing progress note dated 4/27/12 at 5:00 PM documented, " Cons ( consumer) in room took shower then came to nurses station with wound vac drsg (dressing) balled up in hand stating she needed another drsg. ABD (abdominal) pad applied to suture site and windowed with paper tape."

There was no order in the medical record for the wound care provided by the nurse and no documented contact with the physician for a wound care order.

There was no documentation of where the one to one staff member was that was suppose to have been with the patient when she removed the dressing that was have to remained until 5/1/12 according to the orders received from the referring hospital.

The nursing progress note dated 4/28/12 at 9:40 AM documented, "No complaints 1:1 staff present." 11:30 AM, " Drsng change to mid abd incision performed, site clean dry with staples, staple line edges approximated. " There was no documentation of what type of wound care was performed and no order in the medical record for wound care.

The consult was completed by the nurse practitioner 4/29/12, documented, " Lt (left) ear canal swollen, red with exudate- unable to visualize tympanic membrane due to edema and ear pain."

The nurse practitioner ordered Augmentin 875 mg ( milligrams) by mouth two times a day for 7 days. There was no entry regarding the surgical incision.

The nursing progress note dated 4/29/12 at 9:30 PM documented, "Administered meds at nurses station plus ... bandage re-taped with paper tape... stitches well healed no oozing or redness around sutures."

There was no indication the dressing was changed but a wound assessment was documented and still no orders for wound care or dressing changes.

A medical consult form completed by the nurse 4/30/12 was for evaluation and removal of abdominal staples.

The nursing progress note dated 4/30/12 at 1:10 PM documented, " Drsg changed to abdomen, no signs/symptoms of infection noted no drainage observed."

The response written on the form from the nurse practitioner on 5/1/12 at 2:30 PM documented, " Midline incision with 25 staples. Wound well approximated staples removed."

The nursing progress note dated 5/1/12 at 6:35 PM documented, " Cons observed abdominal incision dehisced 1 inch, orders received steri strip wound. Wound cleansed and steri strips applied."

There was no order in the medical record for steri strips or wound care.

The nursing progress note dated 5/1/12 at 9:38 PM documented, " Consumer noted with 1:1 staff. Cons c/o ( complain of) abd wound draining. No drainage noted by this writer. Consumer abd wound noted with small areas where the wound has dehiscence no purulent discharge noted to area... covered with sterile gauze until evaluated by MD ( medical doctor).

A medical consult form completed by the nurse 5/2/12 was for evaluate and treat wound dehiscence.

The nursing progress note dated 5/2/12 at 9:40 PM documented, " Cons wound re-dressed noted approximately 1/2 inch dehiscence of upper part of suture line wound edges approximated no exudate from wound; wound appears."

The response written on the form from the nurse practitioner on 5/3/12 documented, " Small area of dehiscence at upper mid abd incision. No drainage or bleeding, has sterti-strips. For d/c (discharge) tomorrow to follow up with PCP (primary care physician)."

The patient was discharged 5/4/12 with instructions to follow up with her primary care physician. There was no documented orders in the medical record for wound care, no follow up appointment scheduled with the PCP and no documentation of wound care being taught to the patient or supplies provided for the patient to perform any wound care.

In an interview with Employee Identifier # 1, the Director of Performance Improvement, on 6/7/12 at 10:30 AM, it was confirmed there were no orders for wound care and the nurse failed to write an order for the application of steri-strips.



17650

3. MR # 10 was admitted to the adolescent psychiatric unit on 3/14/12 with an Axis I diagnosis of Psychosis.

Review of the Progress Notes dated 3/14/12 at 1:00 PM revealed the the patient began fighting with the staff and the nurse administered Lorazepam 1 mg IM (intramuscular)with Benadryl 50 mg IM.

Review of the Physician Orders dated 3/14/12 revealed an order documented at 2:21 PM for Ativan (Lorazepam) 2 mg with Benadryl 50 mg IM for acute agitation. There was no documentation of a physician's order for the Lorazepam and Benadryl administered at 1:00 PM.

An interview was conducted with EI # 1 on 6/7/12 at 10:40 AM. The surveyor requested the physician's order for the Lorazepam and Benadryl administered on 3/14/12 at 1:00 PM. EI # 1 stated the order was written after the administration for the medication.

Based on record review and interview with staff it was determined the facility failed to include the times for documented therapy sessions for 7 of 7 current patients. This affected Medical Records (MR) #'s 1, 2, 5, 6, 7, 8 and 9 and had the potential to affect all patients served.

Findings include:

The therapy sessions reviewed for MR #'s 1, 2, 5, 6, 7, 8 and 9, to include individual, group and recreational, failed to include the start and ending times resulting in an inability to determine if adequate treatments were provided.

An interview conducted on 6/07/12 at 10:30 AM with Employee Identifier (EI) # 1, Director of Performance Improvement, confirmed the above.

Based on observations, review of the facility's policy and procedure and interviews it was determined the facility failed to ensure the pharmacist was ensuring the hospital staff were following the policies and procedures for medications storage.

Findings include:

Facility Policy: Medication Storage, Control, and Assistance and Administration. # CTS 3.0

...Inpatient Programs

Consumers (patients) are encouraged to bring their currently prescribed medications to the programs at the time of admission to assist the physician with the history/intake evaluation. Such medications should preferably be removed from the programs premises at the conclusion of the admission or should be packaged and stored with the consumer's other belongings and returned to the consumer at the time of discharge.

If it is necessary for a consumer to continue therapy on a medication that is not normally available from the pharmacy, the consumer's own supply may be used provided the conditions below are met...

The consumer's own medication is identified by a pharmacist at the designated pharmacy.

c. If the medication cannot be identified, is adultered, or otherwise unsuitable for use, the nurse will notify the consumer's physician, and the consumer's own meds cannot be used.

Facility Policy: Disposition of Unused Medications # MM 1.5

Policy:

To ensure the safety of consumer, staff and others, an appropriate means for disposal of unused prescribed and stock medications is necessary. The method of disposal will at all times be in accordance with...(the facility's name) pharmacy guidelines.

Procedure:

1. In cases where the medication was not sent to the program by an...(facility) pharmacy (i.e., brought by the family and/or guardian of a consumer):

The program's nurse will return unused doses of medication to the family and/or guardian.

If the family and/or guardian decline to have the medication returned to them, the medication will be returned to the...(facility) pharmacy for disposal.

An initial tour of the Adult Medication Room was conducted on 6/5/12 at 11:30 AM. Upon entering the Medication Room the surveyors noted a plastic bag full of medication bottles on the counter and a paper bag full of medication bottles in the sink. The surveyors asked the nursing staff why the plastic and paper bag full of medications bottles were in the medication room and the response was, "for disposal".

Further review of the medication room on the adult unit revealed a bottle of Glyburide/Metformin 2.5/500 which was filled 9/6/11 and Meloxicam 7.5 mg (milligram) which was filled 10/11/11 both for Patient Identifier # 13. These bottles of medication were sitting next to 2 bottles of medication the patient was currently receiving at the hospital.

The surveyor then asked EI # 5, Registered Nurse # 1, what the policy was for administering a patients' home medication. EI # 5 stated the medication was reviewed by the pharmacist and then administered by the nursing staff. The surveyor asked how the nursing staff knew that a home medication was what the label read. The response was the pharmacist reviewed the medication. The surveyor the asked how this was documented and the response was, "it is not documented anywhere we just verbally pass it to the next nurse".

An interview was conducted with Employee Identifier # 4, the Pharmacist on 6/5/12 at 11:45 AM. The surveyor asked what the process was for the nursing staff to administer a patients' home medication. EI # 4 replied, "I look to see what medication is and if I am not here the nursing staff use the Ident drug book." The surveyor asked what documentation there was to show the pharmacist verified the medication and the response was, "there is none".

An interview was conducted on 6/6/12 at 8:30 AM with EI # 10, RN # 2. The surveyor asked EI # 10 to review the process for administering a patients' home medication. EI # 10 stated the pharmacist would verify the medication. The surveyor asked how this was documented and the response was, "I guess it is in the pharmacy".



08538

On 6/07/12 at 9:00 AM a tour of the Adult Medication Room was conducted by the surveyor and EI # 3, Director of Nursing and EI #5, the Hospital Administrator. Three plastic bags of medication bottles were observed on the counter in a metal bin. The surveyor asked EI # 3 why the medications observed on 6/05/12 were still in the medication room. EI # 3 confirmed the medications should have been sent back to the pharmacy for disposal or return.

Based on observations, review of the facilities policies and procedures and interviews, it was determined the facility failed to ensure the staff followed the facility policy for Infection Control for Refrigeration of Foods, Medication and Specimens. This had the potential to negatively affect all patients being served by this facility.

Findings include:

Facility Policy: Refrigeration of Foods, Medication and Specimens # IC 3.6

Policy:

To reduce the risk of cross contamination...(name of the company) maintains separate refrigerators for food, medications, and specimens.

A tour of the Pharmacy was conducted on 6/5/12 at 1:15 PM by the surveyor and Employee Identifier (EI) # 3, the Director of Nursing. The refrigerator designated to store patients' medications contained Hot Dogs, mustard, cheese slices, salad dressing, butter, spray butter, milk, liquid eggs and jello.

An interview was conducted with EI # 3 at 1:20 PM on 6/5/12 who stated the food was not to be stored in a refrigerator with patients' medications.

EI # 4, the Pharmacist then placed the above listed food in the bottom drawers of the refrigerator. The surveyor asked EI # 3 if that was acceptable and the response was, "No".

Based on review of medical records, interview and review of policy and procedures it was determined in 4 of 7 current records reviewed the treatment plans were not individualized and comprehensive to address the medical and psychosocial needs of the consumers. The treatment plans were not updated with the patient needs. This affected Medical Record (MR) # 1,# 2 ,# 6 and # 9.

Findings include:

Policy: Treatment, Treatment Plan and Review
Revised 2/10

Policy: In order to ensure the appropriateness of care, treatment plans and reviews will be conducted for all consumers...


In accordance with DMH (Department of Mental Health) 3102(2004), services must be individualized, well planned, and should include treatment designed to enhance the consumer's abilities to recover and function in the least restrictive setting.

Procedure:
1. The development and initiation of the treatment plan will begin at intake. Treatment plans should be completed, staffed and signed within 72 hours for inpatient programs.

2. The treatment plan will include clinical issues to be addressed in treatment and the services to be provided to address those issues, in language the consumer can understand. The treatment plan will state the expected outcomes for each goal.

9. Written assessments of the consumer's progress in relation to the treatment plan are documented...

11. The treatment plan is reviewed upon transfer and discharge and is revised as necessary.

12. The treatment plan is reviewed when major changes occur in age, presenting problems or disabilities and is revised as necessary.

Medical Record Findings:


1. MR # 6 was admitted on 5/29/12 to the adult psychiatric unit with Axis I diagnosis of Schizophrenia and Axis III diagnoses including Deafness and Mute, Mental Retardation and Seizures.

A review of the Hospital Treatment Plan, dated 6/01/12, included, "Criteria for discharge (long term goal): ...will exhibit a decrease in Hallucinations and unstable mood. Consumer strengths/assets which facilitate achievement of treatment goals: Good physical health, support of family and friend. Liabilities/weakness and special needs-possible barriers to treatment: Hearing, Legal issues, Medication non-compliance and Speech.

The master problems included Hallucinations and Medication Non-compliance. The plan did not include any possible barriers in care due this patient's hearing impairment.

MR # 6 was observed on 6/05/12 from 1:05 PM to 1:15 PM in the sitting area, secluded from others, staring at the floor and fidgety. No one interacted with him at this time. On 6/05/12, from 1:40 PM to 2:00 PM, MR # 6 was observed arriving ten minutes late to a group therapy session. Seven patients and two staff members were present. A worksheet handout titled stress was distributed to all the patients. MR # 6 looked at the handout and made hand gestures occasionally laughing to himself. At one point the therapist went over and directed him to the page she was discussing. There was no interpreter present at this session who could effectively communicate to determine his response and understanding of the subject matter.

An interview on 6/05/12 at 2:40 PM with Employee Identifier (EI) # 8, Behavioral Aide, revealed an interpreter comes once a day to a care team meeting. EI # 8 stated she did not know sign language and MR # 6 would read lips and use hand gestures. EI # 8 stated MR # 6 required 1:1 observation and had been very aggressive on admission.

A review of group therapy sessions from 5/31/12 to 6/04/12 revealed the following:

5/31/12 Topic: Therapy Mental Illness. Consumer response: .... attended group and completed his worksheet. He was signing to himself during group and appeared to be upset with someone or something. There was no interpreter present at this time.

6/01/12 Topic: Drug and alcohol use. Consumer response: ...attended group but did not participate due to communication barrier. ...did not complete a self assessment feedback form. There was no interpreter present at this time.

6/03/12 Topic: Stress Reduction. Cons (consumer) did not attend.

6/04/12 Topic: Exercise. Cons did not attend group.

6/04/12 Topic: Therapy Discharge Planning. consumer response: ...did not attend group today.

6/05/12 Topic: Awareness of thoughts or messages and mood. Intervention: ...attended group. He looked at the board at times in group. He was unable to share and actively participate due to hearing and speech impairment. There was no interpreter present at this time.

An interview on 6/07/12 at 10:04 AM with Employee Identifier (EI) # 1, Director of Performance Improvement, confirmed the communication barrier between staff and MR # 6.




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2. MR # 1 was admitted to the facility on 5/25/12 with Axis I diagnoses of Major Depressive Disorder, Moderate without Psychotic features, Sexual Abuse of a Child, Victim Posttraumatic Stress Disorder, Chronic Parent-Child Relational Problems, Child-Sibling Relational Problems, Learning Disorder, Not Otherwise Specified and Rule Out Reactive Attachment Disorder, Disinhibited Type.

The Treatment Plan was formulated 5/25/12 and the initial plan dated 6/5/12.

The Master Problems listed were as follows:
Problem: Cons (consumer) exhibits poor impulse control.
Short term goals: Will reduce irritability and impulsivity and increase normal social interactions three times a week as evidenced by verbalizing feelings of frustration, disagreement, and anger in a non aggressive manner.
Problem: Potential for pain (chipped tooth).
Short term goals:Cons will maintain pain of less than 5/10 on pain scale.

A hospital treatment plan meeting dated 6/1/12 documented the same master problem of Cons exhibits poor impulse control. The goal was documented the same and there was no documentation to show any change to goals or interventions and no documentation of improvement.

A hospital treatment plan meeting dated 6/4/12 documented the same master problem of Cons exhibits poor impulse control. The goal was documented the same and there was no documentation to show any change to goals or interventions and no documentation of improvement.

The consumer continued to exhibit behaviors which required time out and medications to control his/her behaviors.

In an interview with Employee Identifier (EI) # 1, the Director of Performance Improvement, on 6/7/12 at 11:30 AM, it was confirmed that the treatment plan had not been changed. EI # 1 stated that the new computer system did not have a place to document updates and or changes to goals and interventions.

3. MR # 2 was admitted to the facility on 5/28/12 with Axis I diagnoses of Major Depressive Disorder, Moderate, without Psychotic Behavior, Oppositional Defiant Disorder, parent-Child Relational Problems, Sibling-Child Relational Disorder, Attention Deficit Hyperactivity Disorder and Possible Physical Abuse Child, Victim.

The initial treatment plan was dated 5/29/12 with the master problem list as follows:
Problem: Potential for disturbed sleep
Short term goal: Cons will obtain at least 8 hours of sleep nightly.
Problem: Hallucinations
Short term goal: Will have three out of five days upon which she will deny having any hallucinations.

The updated plan was dated 5/30/12 with the same problems and goals. The treatment plan was not changed or the interventions to meet the goals. The patient was discharged 6/5/12 and no change had been made to the treatment plan and no documentation the goals or discharge criteria were met.

The consumer continued to require redirection and participated poorly in group. The therapist tried different types of interventions with the consumer but failed to change any interventions or goals on the treatment plan.

In an interview with EI # 1,on 6/7/12 at 9:50 AM, it was confirmed that the treatment plan had not been changed.





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4. MR # 9 was admitted to the Adolescent Unit on 6/1/12 with Axis I diagnoses including Major Depressive Disorder, History of Bipolar Disorder, and Oppositional Defiant Disorder.

Review of the Initial Treatment Plan dated 6/1/12 revealed no documentation of the team who approved and developed the plan.

Review of the Updated Plan dated 6/4/12 revealed only attended by the physician and the nurse. There was no documentation the therapist attended the plan meeting and assisted in the update.

An interview was conducted on 6/7/12 at 10:30 AM with EI # 1 who verified the above.

Based on review of medical records, facility contracts and interview it was determined the facility failed to ensure all staff utilized in patient care were adequately trained to provide safe care to the patients and had completed the orientation to the facility's policies and procedures. This affected Employee Identifier (EI) # 6 and EI # 7 and had the potential to affect all patients served by this facility.


Findings include:

Facility Staffing Agreement entered in to February 2002 and amended July 27, 2010.

Article 4. Mutual Responsibilities
Orientation: Maxim will cooperate with Facility to provide Maxim personnel with an adequate and timely orientation to Facility. At a minimum, Facility will orient Maxim personnel to its hazard communication procedures and the Facility specific Exposure Control Plan as it pertains to OSHA (Occupational Safety & Health Administration) requirements for bloodborne pathogens.

Facility Policy: MindSet-New Employee Orientation

Policy:
MindSet training will be provided during new employee orientation to those employees who provide direct consumer care as mandated by the Joint Commission and the Alabama Department of Mental Health, or as otherwise requested in writing by program supervisors...

MindSet will include the following components:
Introduction- 30 minutes
MindSet principles- 3.0 hours
MindSet Communication- 1.5 hours
Avoiding contact- 1.0 hour
Physical contact- 4.0 hours
Vertical/Horizontal Containment- 2.5 hours

The MindSet training staff will stress that the organization believes that the consumer has the right to be free from seclusion and restraint and that the organization's goal is to be seclusion and restraint free...

Participants will be tested on knowledge gained in the form of a written exam and a skill test...

MindSet re-certification must be obtained prior to the expiration date of the initial certification and every two years (prior to expiration) thereafter.

In an interview with Employee Identifier (EI) # 1, the Director of Performance Improvement on 6/6/12 at 2:05 PM, it was confirmed that all staff must be trained in " MindSet" before working alone on the floor with patients.

Medical Record (MR) Findings:

1. MR # 1 was admitted to the facility on 5/25/12 with Axis I diagnoses of Major Depressive Disorder, Moderate without Psychotic features, Sexual Abuse of a child, victim, Post Traumatic Stress disorder and Parent-Child Relational Problems.

The e-MAR ( electronic medication administration record) included documentation for EI # 6, Maxim Registered Nurse(RN) on 5/26/12 and 5/27/12. This RN had no orientation to work on the children's unit and no MindSet training. EI # 1 was asked for personnel files or training records on EI # 6 on 6/6/12 at 2:05 PM and EI # 1 stated that she had no documentation of training.

2. MR # 4 was admitted to the facility on 4/27/12 with Axis I diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, Attention Deficit Hyperactivity Disorder and Combined Type Parent/Sibling Relational Problems.

The e-MAR included documentation for EI # 7, Maxim Registered Nurse(RN) on 4/28/12 and 4/29/12. This RN had no orientation to work on the children's unit and no MindSet training. EI # 1 was asked for personnel files or training records on EI # 7 on 6/6/12 at 2:05 PM and EI # 1 stated that she had no documentation of training

In an interview with EI # 1, the Director of Performance Improvement on 6/6/12 at 2:05 PM, she stated that absolutely everyone was to go through orientation and MindSet training.