HospitalInspections.org

Based on document review and interview, the facility failed to maintain a current list for 1 (nursing) of 7 contracted services.

Findings include:

1. In interview on 06-24-2019 at 11:40 am, employee #A1, Director of Inpatient Services, indicated the facility contracted for 7 services, including the service of nursing.

2. On the above-stated date and time, employee #A1 was requested to provide documentation of a list of all contracted services, including the scope and nature of the services provided.

3. Review of a facility document of contracted services, indicated it did not include a listing of the contracted service of nursing.

4. In interview on 06-26-2019 at 3:25 pm, employee #A7, Director Quality Improvement, confirmed all the above and no other documentation was provided prior to exit.

Based on observation and interview, the facility failed to prevent the presence of ligature risks in the physical environment in one facility.

Findings include:

1. Observation on 6/26/2019, at approximately 11:19 am, with N1 (Licensed Clinical Social Worker/Director of Inpatient Services) the following was observed. Patient rooms 111 and 112 contained ligature risk including the following. Bedrooms contained risk including door knobs, door hinges and door closer rod. Bathrooms contained risk including hand rails and toilet pipes.

2. Observation on 6/26/2019, at approximately 11:26 am, with N1 and N2 (Registered Nurse Supervisor) the following was observed. Room 126 contained ligature risk including door knobs, door hinges and door closing rods. Men's patient bathroom had ligature risk including handrails, shower head and doorknobs.

4. Interview on 6/26/2019, at approximately 2:05 pm, N1 confirmed the above ligature risk.

3. Observation on 6/26/2019, at approximately 1:34 pm, N2 the following was observed. Women's patient bathroom had ligature risk including, handrails, shower head and doorknobs.

5. Interview on 6/26/2019, at approximately 1:34 pm, N2 confirmed the above ligature risk.

Based on document review and interview, the facility failed to ensure qualified personnel with CPR (Cardiopulmonary Resuscitation) training for 1 of 7 (S4 [Registered Nurse]), personnel files reviewed.

Findings include:

1. Review of policy, First Aid & CPR Policy #: ll.A.41, Last Review: 2/26/18, indicated the following. Select staff members are required to be trained in CPR in accordance with his or her Learner Profile on Relias (staff documented training) and then on a bi-annual basis thereafter. These select staff are ... all inpatient unit staff members...

2. Review of S4's personnel file and Relias indicated CPR training renewal due 01/14/2017.

3. Interview on 6/26/2019, with N6 (Human Resources Assistant) confirmed S4's CPR renewal date was 01/14/2017.

Based on document review and interview, the facility failed to measure, analyze, and track quality indicators that assess processes of 1 (contract nursing) of 44 direct and contracted hospital services in its quality assessment and performance improvement (QAPI) program for calendar 2018.

Findings include:

1. Review of the facility's QAPI program for calendar year 2018 indicated it did not include the service of contract nursing.

2. in interview on 06-26-2019 at 2:20 pm, employee #A7, Director Quality Improvement, confirmed the above and no other documentation was provided prior to exit.

Based on document review and interview, the medical staff failed to follow its policy to conduct appraisals for 2 physicians (MD#1 and MD#2) of 6 physician credential files reviewed.

Findings include:

1. Review of a facility document titled PROFESSIONAL STAFF BYLAWS, last approved 04/18/2012, indicated the PAC [Professional Advisory Committee] shall review relevant past and present professional performance since the last credentialing period, and that two-year appointments may be granted.

2. Review of 6 physician staff credentialing files indicated file MD#1 had last been re-appointed on 04-17-2019, thus the last re-appointment would have been no later than 04-17-2017. Further review of the file indicated the last time an appraisal had occurred was 05-05-2014. Thus, the last review of relevant past and present professional performance had not been performed since the last credentialing period ( 04-17-2017 through 04-17-2019).

3. Review of 6 physician staff credentialing files indicated file MD#2 had last been re-appointed on 02-21-2018, thus the last re-appointment would have been no later than 02-21-2016. Further review of the file indicated the last time an appraisal had occurred was 02-21-2014. Thus, the last review of relevant past and present professional performance had not been performed since the last credentialing period (02-21-2016 through 02-21-2018).

4. In interview on 06-26-2019, employee #A5, Chief Executive Officer, confirmed all the above and no other documentation was provided prior to exit.

Based on document review and interview, the facility failed to ensure annual evaluation of 1 of 7 (S5 [Licensed Practical Nurse]) personnel files reviewed.

Findings include:

1. Review of facility policy, Performance Appraisal, Policy #: Lll.A.18. LAST REVIEW: 9/17/18, indicated the following. Performance evaluations shall be conducted on all CMHC (Community Mental Health Center) employees at the completion of their introductory period and annually thereafter.

2. Review of S5's personnel file indicated last evaluation 9/15/16.

3. Interview on 6/26/2019, at 10:33 am, with N6 (Human Resource Assistant) confirmed the above.

Based on document review and interview, the hospital failed to document a preventive maintenance (PM) schedule for 2 (oto/laryngoscope and patient scale) of 4 pieces of clinical equipment, and failed to document preventive maintenance performed in calendar year 2018 and year 2019 to-date for 2 (oto/laryngoscope and patient scale) of 4 pieces of clinical equipment.

Findings include:

1. Review of facility documents indicated there was no documentation of a PM schedule for an oto/laryngoscope and a patient scale.

2. Review of facility documents indicated there was no documentation of a PM performed in calendar year 2018 and year 2019 to-date for an oto/laryngoscope and a patient scale.

3. In interview on 06-26-2019 at 3:25 pm, employee #A7, Director Quality Improvement, confirmed all the above and no other documentation was provided prior to exit.

Based on observation, the facility created a condition which resulted in a hazard to patients, public or employees in 1 instance.

Findings include:

1. On 06-26-2019 at 10:55 am in the presence of employee #A4, Director Intensive Family Services, it was observed at Outpatient Facility #1, Lawrenceburg Intensive Family Services, in Room #3, there was an alcohol-based hand sanitizer (ABHS) on the wall directly above a telephone outlet. This posed a fire hazard if the flammable alcohol dropped into the electrical ignition source.

Based on document review and interview, the facility failed to ensure S3 (Nurse Supervisor/Registered Nurse/Infection Control Officer) had ongoing Infection Control Officer training in one facility.

Findings include:

1. Review of S3's personnel file lacked indication of previous or ongoing Infection Control Officer Training.

2. Interview with N5 (Director of Quality Improvement) confirmed S3 had no previous or ongoing infection control officer training.

Based on observation, the facility created 1 condition which failed to provide a healthful environment that minimized infection exposure and risk to patients, employees and visitors for 1 hospital.

Findings include:

1. On 06-26-2019 at 11:30 am, in the presence of employee #A6, Outpatient Division Director, at Outpatient Clinic #2, Dearborn County Outpatient Counseling Center, it was observed in 5 different corridor ceiling light fixtures, there were what appeared to be several dead insects in each of the fixtures.

Based on record review and interview the facility failed to provide:

1. Psychiatric Evaluations (called "Admission Note To Inpatient Unit" by this facility) for five (5) of six (6) active sample patients (A1, A2, A4, A5 and A6), and two (2) of two (2) none active sample patients (B1 and B2) chosen from a list of discharged patients to review the medical record standards; included an descriptive estimate of the patient's intellectual functioning, orientation and memory. This deficiency compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

2. Psychiatric Evaluation to note patient assets in the psychiatric assessment in descriptive, none interpretive fashion, for four (4) of six (6) active sample patients (A3, A4, A5 and A6) and two (2) of two (2) none active sample patients (B1 and B2). This lack of identifying patient's assets inhibits the treatment team's ability to formulate treatment plans that utilize patient strengths as a basis for treatment interventions. (Refer to B 117)

3. Master Treatment Plans (MTPs) that included substantiated psychiatric diagnoses that would form the basis for treatment for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5, and A6, and two (2) of two (2) non sample patients (B1 and B2) ) chosen for the review of medical records. The absence of substantiated diagnoses on patients' MTPs compromises the ability of the treatment team to identify specific psychiatric and physical problems and to plan effective treatment for which specific treatment modalities would be delineated and implemented during the current hospitalization. (Refer to B120)

4. Master Treatment Plans (MTPs) that identified patient-related long-term and short-term goals stated in observable, measurable, behavioral terms for six (6 ) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) none active sample patients (B7 and B8) chosen from the list of discharged patients. This failure hinders the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the Master Treatment Plans in response to patients need. (Refer to B121)

Master Treatment Plans (MTPs) that identified physician, nursing and social work interventions that were individualized and specific to the treatment needs for six (6 ) of six (6) active sample patients (A1, A2, A3, A4, A5, and A6) and two (2) of two (2) non-active sample patients (B1 and B2) chosen for the list of discharged patients. The Master Treatment Plans contained interventions that were routine assessment and generic routine job functions. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

Based on record review and interview, the facility failed to ensure that the Psychiatric Evaluations for five (5) of six (6) active sample patients (A1, A2, A4, A5 and A6), and two (2) of two (2) none active sample patients (B1 and B2) chosen from a list of discharged patients; included an estimate of the patient's intellectual functioning, orientation and memory. This deficiency compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review:

The Initial Psychiatric Evaluations of the following patients were reviewed (dates of evaluations are in parentheses): A1 (6/28/19); A2 (6/29/19); A4 (6/25/19); A5 (6/30/19); A6 (6/27/19); B1 (4/2/19); and B2 (5/21/19). This review revealed:

1. Patient A1: In the section of the "Mental Status Examination" (MSE) the following was noted:" Orientated with good memory. The psychiatric evaluation failed to address intellectual functioning. No evidence for determining the assessment of "good memory" was provided.

2. Patient A2: In the section of the "Mental Status Examination" (MSE) the psychiatric evaluation failed to address intellectual functioning, memory and orientation.

3. Patient A4: In the section of the "Mental Status Examination" (MSE) the following was noted: "Limited insight." No evidence for determining the assessment of "limited insight" was provided

4. Patient A5: In the section of the "Mental Status Examination" (MSE) the following was noted: "average intelligence, no issue with memory, limited insight." No evidence for determining the assessment of "average intelligence, memory and limited insight" was provided.

5. Patient A6: In the section of the "Mental Status Examination" (MSE) the psychiatric evaluation failed to address intellectual functioning, memory and orientation.

6. Patient B1: In the section of the "Mental Status Examination" (MSE) the following was noted:
"Recent and remote memory intact. Limited insight/judgement." The psychiatric evaluation failed to address orientation. No evidence for determining the assessment of "Recent and remote memory intact. Limited insight/judgement."

7. Patient B2: In the section of the "Mental Status Examination" (MSE) the following was noted:
"Recent and remote memory intact. Good focus /concentration. Fair to limited insight/judgement." The psychiatric evaluation failed to address orientation. No evidence for determining the assessment of "Recent and remote memory intact. Good focus/concentration. Limited insight/judgement."

B. Interview

During an interview on 7/2/19 at 10:00 a.m. with the Medical Director the assessment of patient's intellectual function, memory and orientation as listed on the psychiatric evaluation were discussed. The Medical Director stated his agreement with the findings and stated that they will be improved.

Based on record review and interview, the facility failed to note patient assets in the psychiatric assessment in descriptive, none interpretive fashion, for four (4) of six (6) active sample patients (A3, A4, A5 and A6) and two (2) of two (2) none active sample patients (B1 and B2). This lack of identifying patient's assets inhibits the treatment team's ability to formulate treatment plans that utilize patient strengths as a basis for treatment interventions.

Findings include:

A. Record Review:

1. Patient A3- psychiatric evaluation dated 7/2/19

The only asset listed for this patient was stated as "I like to spend time with my kids." There was no personal skills or achievements listed for this patient.

2. Patient A4- psychiatric evaluation dated 6/25/19

The only asset listed for this patient was stated as "I like to spend time with my parent." There was no personal skills or achievements listed for this patient.

3. Patient A5- psychiatric evaluation dated 6/30/19

The only asset listed for this patient was stated as "I like to spend time with my mother and sister." There was no personal skills or achievements listed for this patient.

4. Patient A6- psychiatric evaluation dated 6/27/19

There was no asset listed for this patient. Under title "Assets" "None identified." There were no personal skills or achievements listed for this patient.

B. Interview

During an interview on 7/2/19 at 10:00 a.m. with the Medical Director the none specific strengths/assets listed on the psychiatric evaluation were discussed. The Medical Director stated he concurred with the findings.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that included substantiation of the psychiatric diagnoses that would form the basis for treatment for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5, and A6, and two (2) of two (2) non sample patients (B1 and B2) ) chosen for the review of medical records. The absence of substantiated diagnoses on patients' MTPs compromises the ability of the treatment team to identify specific psychiatric and physical problems and to plan effective treatment for which specific treatment modalities would be delineated and implemented during the current hospitalization.

Findings include:

A. Record Review

The MTPs for the following active sample patients were reviewed (dates of plans in parentheses): A1 (6/26/19), A2 (6/29/19), A3 (6/28/19), A4 (6/25/19), A5 (6/30/19), A6 (6/27/19), and non-sample patients B1 (4/3/19), and B2 (5/20/19). This review revealed that none of the MTPs contained substantiated psychiatric diagnoses.

B. Interviews

1. During the interview on 7/3/19 at a.m. with the APRN (Advanced Practice Registered Nurse), the missing substantiated diagnoses on MTPs were discussed. She stated, "I agree".

2. During the interview on 7/3/19 at 9:30 a.m. with the Psychiatrist -2 the missing substantiated diagnosis in the MTP's was discussed. He agreed with the findings and stated, "sometimes we take short cuts."

Based on record review, interview, the facility failed to provide Master Treatment Plans (MTPs) that identified patient-related long-term and short-term goals stated in observable, measurable, behavioral terms for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) none active sample patients (B7 and B8) chosen from the list of discharged patients. This failure hinders the treatment team's ability to measure behavioral changes in the patients and may contribute to failure of the team to modify the Master Treatment Plans in response to patients need.

Findings include:

A. Record Review

1. Patient A1: MTP dated 6/26/19, for problem "Risk for suicide." The short-term goals were stated as, "Patient will remain safe while in the hospital, with the aid of nursing intervention and support. Patient will make a no suicide contact with the nurse covering the next 24 hours, then renegotiate the terms at that time. Patient will stay with a friend or family if [he/she] still has potential for suicide after discharge. Patient will have links to self-help groups in the community." Goals were not measurable and were staff expectations and/or describe hospital routine functions.

2. Patient A2: MTP dated 6/29/19, for problem "Potential for self-harm r/t (related to) unresolved grief issues with poorly or none integrated healthful coping skills prior to pt's (patient's) Adm (admission)." The short-term goals were stated as, "Patient will have a written safety plan at time of d/c (discharge) and have no thoughts of self-harm by 7/5/2019. Patient will provide daily tx (treatment) goals being assisted by staff with completing and processing daily and PRN (as necessary) and attend 75% of the suicidal groups. Patient will discuss current coping skill (ie) (that is) drinking alcohol.......(unable to read) and potentially define more effective coping r/t to [his/her] father's passing by 7/5/2019." Goals were not measurable and were staff expectations statements that did not reflect what the patient would be doing or saying to validate "no thoughts of self-harm."

3. Patient A3: MTP dated 6/28/19, for problem "Ineffective individualized coping r/t inadequate opportunity to prepare for a stressor." The short-term goal was stated as, "Patient will keep self and others safe while on the unit." Goal was not measurable and did not address identified behavior what the patient would be doing or saying to keep "self and others" safe, nor was it observable; was a staff expectation statement.

4. Patient A4: MTP dated 6/25/19, for problem "Risk for self-harm and suicide." The short-term goals were stated as, "Patient will complete safety plan prior to discharge (be safe of the unit). Patient will seek out staff if/when having thoughts of self-harm. Patient will define a list of at least 2 new coping skills within three days of admission [sic]." Goals were not written in observable or measurable behaviors to be achieved; they were staff expectation statements.

5. Patient A5: MTP dated 6/30/19, for problem "Risk for self-directed harm." The short-term goal was stated as, "Patient will remain free from harm for self and others and contract for safety within 24 hours." Goal was not measurable or observable and was a staff expectation statement.

6. Patient A6: MTP dated 7/27/19, for problem "Risk for suicide." The short-term goals were stated as, "Patient will remain safe while in the hospital with the aid of nursing intervention. Patient will stay with friends or family if person still has potential for suicide after discharge. Patient will have links to self-help groups in the community to use after discharge." Goals were staff expectation statements and routine hospital functions.

7. Patient B7: MTP dated 4/3/19, for problem "Potential for self-harm r/t chronic mental illness."
The short-term goals were stated as, "Patient will have a completed safety plan by time of d/c (discharge), will not attempt to harm self-whilst hospitalized. Patient will provide daily tx goals and be active in the milieu, attending 50% of the scheduled groups and being out of [his/her] room 50% of the day." Goal were staff expectation statements/compliance in treatment rather than behavior outcomes to be evaluated

8. Patient B8: MTP dated 5/20/19, for the problem "Ineffective coping." The short-term goals were stated as, "Patient will state that [he/she] feels comfortable with one new coping skill within 72 hours." The goal was written as staff expectation statement, and not a patient goal.

B. Interview

1. During an interview on 7/2/19 at 11:10 a.m. with the Nursing Director the MTP goals were discussed. The Nursing Director agreed with the findings and stated; "they definitely need to be more specific."

2. During an interview on 7/2/19 at 1:40 p.m. with RN 1, the nursing goals were discussed. RN 1 agreed that the goals were staff goals and not patient goals and were not written in observable, measurable and in behavioral terms.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified physician, nursing and social work interventions that were individualized and specific to the treatment needs for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5, and A6) and two (2) of two (2) non-active sample patients (B1 and B2) chosen for the list of discharged patients. The Master Treatment Plans contained interventions that were routine assessment and generic routine job functions. These failures result in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record review

1. Patient A1: MTP date 6/26/19, included the problem of: "Risk for suicide." The following generic and routine discipline functions were listed as active treatment interventions on the plan:

Physician: "Psychiatry will observe daily X 15 mins. For signs of withdrawal. Monitor BP [Blood Pressure] while sedated. Then will evaluate for underlying issues and make recommendations for OP [outpatient] tx. For drug rehab or psychotherapy."

Nursing: "Nursing will continue to emphasize the following: crisis is temporary, unbearable pain can be survived, help is available, and you are not alone. Keep accurate and through records of patient's behavior. Encourage to talk about feelings and problem solve alternatives. Create a no-suicide contract between patient and nurse."

Activity Therapy: "Activity therapy will offer resources on positive coping skills by day 3 to help patient be successful in [his/her] recovery."

Social Services: "Social Services will offer pt. the opportunity to talk daily while on IPU to vent any negative thoughts feelings related to mental illness. Assist pt. with planning for a safe D/C [Discharge] home. Offer recovery resources, contact family support [brother/sister] as needed.

2. Patient A2: MTP date 6/29/19, included the problem of: "Potential for self-harm r/t unresolved grief issues with poorly or non-integrated healthful coping skills prior to pt.'s adm. [admission]." The following generic and routine discipline functions were listed as active treatment interventions on the plan:

Physician: "Psychiatry will monitor s/s [signs and symptoms] of depression, including suicidal thought. Monitor medications efficacy and side effects. Monitor s/s of withdrawal from alcohol. Discuss about alcohol use disorder and coping skill and encourage therapy and groups."

Nursing: "Nursing will assess daily until completed with safety plan. Assist daily clt's potential thoughts of self-harm and provide PRN meds and support PRN. Encourage individual daily tx. Goals processing with staff each day. Encourage group attendance and milieu involvement daily. Provide bid [twice daily] 1:1's targeting more effective .... And healthful coping skill def. and practice by 7/5/2019."

Activity Therapy: "Activity therapy will offer resources on positive coping skills and stress management by day 3 to help patient with grief."

3. Patient A3: MTP date 6/28/19, included the problem of: "Ineffective individualized coping r/t inadequate opportunity to prepare for stressor." The following generic and routine discipline functions were listed as active treatment interventions on the plan:

Nursing: "Nursing will provide 15 mins precautionary checks to maintain client's safety on the unit."

Activity Therapy: "Activity therapy will offer resources on positive coping skills and stress management by day 3 to help patient [his/her] stressors."

4. Patient A4: MTP date 6/25/19, included the problem of: "Risk for self-harm suicide." The following generic and routine discipline functions were listed as active treatment interventions on the plan:

Physician: "Psychiatry will monitor s/s [signs and symptoms] of mania and paranoia. Sleep problem. Monitor medications efficacy and side effects and alternative. Discuss about adherence with treatment and therapy. Discuss coping skill."

Nursing: "Provide or assist pt. with safety plan. Encourage pt. to talk about feelings and alt. [alternative] solutions. Encourage pt. to attend groups, provide information for new coping skills."

Activity Therapy: "Assist pt. with identifying coping skills related to life stressors."

5. Patient A5: MTP, dated 6/30/19, included the problem of: "Risk for self-directed harm." The following generic and routine discipline functions were listed as active treatment interventions on the plan:

Physician: "Psychiatry will monitor s/s [signs and symptoms] of depressive d/c ... and chronic suicidal thoughts. Monitor medication efficacy and risk, side effect and alternative."

Nursing: "Nursing will provide a safe and therapeutic environment for patient while on IPU [In-Patient Unit]. Provide 15-minute precautionary checks for ensuring patient's safety."

Activity Therapy: "Activity therapy will offer resources on positive coping skills by day 3 to help patient manage thoughts of self-harm in a healthy way."

Social Services: "Social Services will offer pt. the opportunity to talk daily while on the IPU to vent feelings related to increased risk of self-harm. Assist pt. with plans for a safe D/C [Discharge] home, coordinate with family supports."

6. Patient A6: MTP, dated 6/27/19, included the problem of: "Risk for suicide." The following generic and routine discipline were listed as active treatment interventions on the plan:

Nursing: "Nursing will continue to emphasize the following: crisis is temporary, unbearable pain can be survived; you are not alone. Put [him/her] on either precaution or suicide observation, depending on level of suicide potential. Nursing will keep accurate and timely records, document pts activity, usually q15 minute. Encourage p. to talk about [his/her] feelings and problem some alternatives."

Activity Therapy: "Activity therapy will offer resources on positive coping skills by day 3 to help patient manage thoughts of self-harm in a healthy way." This intervention is similar worded for several other patients in the sample.

Social Services: "Social Services will offer pt. the opportunity to talk daily vent any negative thoughts feelings related to increase suicidal thoughts. Assist pt. with plans for a safe D/C [Discharge] home, coordinate with family support [husband/wife] as needed."

7. Patient B1: MTP, dated 4/3/19, included the problem of: "Potential harm for self-harm r/t chronic mental illness." The following generic and routine discipline were listed as active treatment interventions on the plan:

Nursing: "Nursing will assist clt. [Client] with completing [his/her] safety plan daily until completed. Provide bid 1:1 targeting healthful coping skill def. [definition] and practice. Provide daily situation targeting, daily tx. [treatment] goals & assist regarding to be defined [sic]."

Activity Therapy: "Activity therapy will offer resources on positive coping skills by day 3 to help patient manage thoughts of self-harm in a healthy way." This intervention is similar worded for several other patients in the sample.

Social services: "Social services will coordinate D/C plan with pt. regarding housing make referrals as appropriate. Assist with coping skills for increased anger by day 3."

8. Patient B2: MTP, dated 5/20/19, included the problem of: "Ineffective coping." The following generic and routine discipline functions were listed as active treatment interventions on the plan:

Nursing: "Nursing will identify situations that triggers suicidal ideations. Assess pt. strengths and positive coping skills. Assess pts coping behaviors. Assess pts social supports."
Activity Therapy: "Activity therapy will offer resources on positive coping skills by day 3 to help patient manage thoughts of self-harm in a healthy way." This intervention is similar worded for several other patients in the sample.

Social Services: "Social services will offer pt. the opportunity to talk daily, while on IPU to vent negative feelings related to ineffective coping. Assist pt. with safe D/C planning. Make appropriate referrals for potential housing for homelessness."

B. Interview

1. During an interview on 7/2/19 at 11:10 a.m. with the Nursing Director the nursing interventions on the MTPs were discussed. The Nursing Director agreed with the findings.

2. During an interview on 7/2/19 at 1:40 p.m. with RN 1, the nursing interventions on the MTPs were discussed. RN 1 agreed that the interventions were staff routine duties, and did not include the modality, frequency and focus.

Based on record review and interview, the Medical Director failed to ensure that:

I. The psychiatric evaluations for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) non-active sample patients (B1 and B2) included comprehensive information regarding an estimate of intellectual functioning, memory functioning, and orientation. Lack of this necessary clinical information can negatively affect decision-making for further evaluation. (Refer to B116)

II. The psychiatric evaluations included an inventory of each patient's personal assets such as accomplishments, skills, or interests written in descriptive and non-interpretative fashion for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and 2 of 2 non-active sample patients (B1 and B2). This deficiency resulted in the lack of necessary information to guide the treatment team in developing a plan of care for the patient. (Refer to B117)

III. The MTP for each patient include a substantiated diagnosis that would form the basis for the treatment plan for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) none-active sample patients (B1 and B2) chosen for review of the medical record. The absence substantiated diagnosis on patient MTPs compromises the ability of the treatment team to identify specific psychiatric problems and plan effective treatment for which specific modalities would be delineated and implemented during current hospitalization. (Refer to B120)

IV. The individualized MTP identified patient related short-term and long-term goals stated in observable, measurable and behavioral terms for six (6) of six (6) active sample patient (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) none sample patients (B1 and B2). This deficient practice hinders the treatment team's ability to measure behavioral changes and may contribute to failure of the team to modify the MTPs based on progress or lack of progress. (Refer B121)

V. The MTPs evidenced individualized treatment interventions with specific focus, based on individual needs and abilities for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) none sample patients (B1 and B2). Interventions stated on the MTPs were generic monitoring and discipline functions without identifying the modality to be utilized, and frequency of interventions. (Refer to B122)

VI. A credible mortality review was completed for one (1) of one (1) non-sample patient (K1) who died shortly after discharge. The failure to complete a mortality review/root-cause analysis results in the facility missing an opportunity to identify practices that could have contributed to adverse outcomes, educate peers about these failures, and reduce the risk of recurrence of similar adverse events.

Findings include:

A. Record review

VII. Patient K1 was admitted on 6/21/18 with the chief complaint of "Panic attack". Psychiatric evaluation called "Admission Note" by this hospital stated "upon presentation [patient] looked as if [he/she] was nodding out, but [patient] insist [he/she] had [his/her] face in [his/her] palm because of panic. Anxiety is coming from getting a new job, when [he/she] has been without a car and without money. [Patient] lost [his/her] father from MRSA (methicillin resistant staphylococci) from IV (intravenous) drug use, [he/she] is afraid of being 'under water' with mounting stress. [Patient] is divorced with a 4 year old daughter."
The "Mental Status Examination" indicated patient was: "Anxious and shaky, good memory, orientated. No delusions. No HI (homicidal ideation), SI (suicidal ideation) or AVH (auditory visual hallucinations). Thoughts were logical and organized. Affect anxious."

The patient was discharged on 6/22/18 with a diagnosis of "Panic Disorder." Admitting psychiatrist progress note dated [7/11/18 at 3:00 p.m. for 6/22/18 stated; "[Patient] was very focused on going to work on a new job. In fact, the worry caused the panic attack at admission. The anxiety is that so much depends on the job. [Patient] had lost [his/her] car license and could not get transportation, so [patient] could not get to work; and this cascaded into without work and without money, and without money [patient] would not see [his/her] 4 year old daughter ... ...[patient] insisted that [he/she] will lose [his/her] job if held here on an ED (emergency detainment). This being Friday, the ED could detain patient until 6/26/18. [Patient] insist [he/she] was never self or other destructive. I see no SI, HI, AVH, and believed that holding patient involuntary will ironically increase patient stress. Though he was asking for benzo's, patient agreed to take Zaydis 5 mgs PRN for panic until seen again in OP (out-patient). Dx (diagnosis) is opiate use disorder with GAD and panic. Plan DC (discharge) with PRN Zaydis until follow-up with OP at CMHC (Community Mental Health Center)." The patient was found dead at a friend apartment on 7/4/2019.

An autopsy was conducted by the "Hamilton County Coroner's Office on 7/5/18." The final report dated 9/28/18 identified the cause of death as; "Acute morphine overdose with alprazolam also present. Manner of Death: "Accidental." The hospital did not conduct a mortality review.

Interview

1. During an interview with the Director of Quality Improvement on 7/1/19 at 2:30 p.m.; in response to the request for the Mortality Review documents, she responded stating that the facility did not do a review.


2. During an interview with the Medical Director on 7/2/19 at 10:00 a.m. The missed mortality review for patient K1 was discussed. The Medical Director concurred that a review was not done. He stated, "We used to do them all the time, missed a few in year passed and lately we have not been doing them."

3. During an interview with the attending Psychiatrist on 7/3/19 at 09:30 a.m. The death records were reviewed. The attending Psychiatrist stated, "I still do not know I had enough information to detain the patient against [his/her] will; as the patient did not displayed any signs and symptoms of being SI, HI, AVH and was pushing for benzos (benzodiazepines) and keeping [him/her] on an ED (emergency detainment) would have increased his symptoms." When inquired if a mortality review was done, he stated that none was done.

Based on record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. The identified goals in MTPs for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) non-active sample patients (B1 and B2) chosen for the list of discharged patients were observable, measurable and addressed the individual patient presenting problems and needs (Refer to B121).

II. Active treatment interventions implemented by Registered Nurses for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5 and A6) and two (2) of two (2) non-active sample patients (B1 and B2) chosen for the list of discharged patients were not linked to specific treatment goals. The listed nursing intervention was routine, generic discipline functions expected to be regularly provided by nursing staff for all patients and was generic in nature such as, "encourage," "assist," "assess." Interventions were also written as staff expectations/compliance statements. These failures to develop focused, individualized interventions can result in fragmented nursing care, non-compliance with planned treatment and lack of accountability putting the patient at risk for adverse treatment outcomes. (Refer to B122)

Based on record review and interview, the facility failed to provide a therapeutic activity program that ensured an adequate number of qualified therapeutic activities for six (6) of six (6) active sample patients (A1, A2, A3, A4, A5, and A6). No activity therapy staff was available to provide or oversee services on evenings, every other Saturday and Sundays. This failed practice resulted in patients not receiving structured activity therapy groups to assist them in meeting their treatment goals.

A. Record Review

1. A review of the "Group Schedule" for the In-Patient unit revealed that therapeutic activities were scheduled for five days per week and two groups every other Saturday's. There were no group scheduled on Sundays. There were no therapeutic activities offered after 4:00 p.m. during the week.

2. Evening, every other Saturday's and Sunday's activities were assigned to nursing staff (Mental Health Technicians). The only evening group on the schedule titled "Relaxation Group." The group consisted of the nursing staff turning music on for patients to listen to.

B. Interview

1. During an interview on 71/19 at 1.30 p.m. RN-1 the unit schedule was discussed. RN-1 stated that the "Relaxation group was done by the tech and it was music for meditation."

2. During an interview on 7/2/19 at 2:00 p.m. with Activity Therapist (AT)-1 the program schedule was discussed. AT-1 stated, there is one therapist assigned to do groups and the therapist work every other Saturday but not on Sundays. Nursing filled in to cover the Saturday the therapist is not working. In the past a Social services person would cover the other Saturday and evening but not anymore." In regard to the evening "Relaxation Group" AT-1 Stated, the "group is not structured they just put on music and there is no discussion."