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1910 CHEROKEE AVENUE, SW

CULLMAN, AL 35055

PATIENT RIGHTS

Tag No.: A0115

Based on facility observations, review CMS (Centers for Medicare and Medicaid) S&C (survey and certification) Memo (Memorandum) Summary dated 12/8/17, facility Work History Report, policy and procedure and medical record review, it was determined the facility failed to ensure all patient rights were protected and care was provided in a safe environment.

This had the potential to negatively affect all patients admitted to The Sanctuary at The Woodlands.

Findings include:

Please refer to tags A-0144 and 0154 for findings.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on facility tour observations, review CMS (Centers for Medicare and Medicaid) S&C (survey and certification) Memo (Memorandum) Summary dated 12/8/17, the facility Work History Report, and interviews with staff, it was determined the facility failed to:

a) ensure patients were cared for in a safe environment.

b) ensure environmental safety risk assessments identified patient safety risks which included ligature risks and the facility environment safety assessment included a mitigation plan.

These deficient practices had the potential to negatively affect all patients admitted to the psychiatric hospital.

Findings include:

CMS S&C Memo 18-06-Hospitals
Date: December 08, 2017
Subject: Clarification of ligature Risk Policy

...Background
A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. ligature points include shower rails, coat hooks, pipes, bedsteads, window and door frames, ceiling frames, handles, hinges and closures. The most common ligature points and ligatures are doors, hooks, handles, windows, and belt or sheet/towels...The presence of ligature risks in the physical environment of a psychiatric patient compromised the patient's safety...particularly for a patient with suicidal ideation. The hospital Patient's Right Condition of Participation...provided all patients with the right to care in a safe setting....
safety risks in a psychiatric setting include but are not limited to furniture that can be easily moved or thrown, accessible light fixtures; non-tamper proof screws; etc...

During a tour of the facility on 5/7/19 from 10:30 AM to 11:30 AM, the following observations were made on the Geriatric Psychiatric Unit:

1. The hallway exit door was not secured (at the bottom of the door).
2. Fire Extinguisher not secured.
3. Furniture which included night stands and chairs were not secured in all patient rooms.
4. Bed alarm cord, approximately 5 feet long in Room 304, which is a ligature risk, not secured.
5. An electric bed cord unsecured in patient room 305 B was greater than 18 inches, which is a ligature risk.
6. Water faucets in patient showers were a ligature risk, able to be used for hanging/strangulation.
7. Full side rails on bed A and bed B in room 311.
8. Air mattress control power cord on bed in room 308 was approximately 12 feet long which was unsecured and could be easily unplugged and used as ligature.
9. Bed alarm cord unsecured in patient room 307 was approximately 5 feet long.

During the tour of the Geropsychiatic Unit on 5/7/19 at 10:50 AM, an interview with Employee Identifier (EI) # 1, Chief Executive Officer was conducted. EI # 1 reported a daily "walk through" of the units for the purpose of ensuring the environment was safe was conducted by Assistant Director of Nursing and the Director of Plant Operations. The surveyor requested the facility environmental assessment documentation.

During a tour of the facility on 5/7/19 from 11:30 AM to 12:30 PM, the following observations were made on the Adult Psychiatric Unit:

1. Fire Extinguisher not secured.
2. Water faucets in patient showers were a ligature risk, able to be used for hanging/strangulation.
3. Exposed sheetrock in the patient bathroom in room 203 .
4. Peeling window tint in patient room 209.
5. Chairs in all patient rooms were not secured.
6. Bedside table not secured in patient room 201 and 206.
7. Air conditioner plastic covering easily removed, using one hand, exposing the metal electrical components in room 201.
8. No cover on electrical outlet in exam room on adult unit.
9. "Noisy Room" on adult unit had plastic tint peeling from windows. The tint could be easily peeled from window and used for suffocation.
10. Dining room on adult unit had plastic tint peeling from windows.

Review of the facility Work History Report, submitted on 5/9/19 for documentation of environment assessment monitoring by EI # 2, Director of Nurses, revealed no documentation the above environmental patient safety concerns had been identified by facility staff. There was no mitigation plan to correct the patient safety concerns.

In an interview on 5/9/19 at 12:30 PM, EI # 1, confirmed the aforementioned findings.

USE OF RESTRAINT OR SECLUSION

Tag No.: A0154

Based on review of medical records (MR), policy and procedure and interviews, it was determined the staff failed to:

a) Obtain a physician order restraint use.

b) Document the restraint (physical hold) and patient tolerance of the restraint in the MR.

c) Update the treatment plan when a restraint was performed.

c) Ensure all patient rights were protected during the physical hold.

This affected Patient Identifier (PI) # 2, 1 of 1 records reviewed for restraint use and had the potential to affect all patients served by this facility.

Findings include:

Policy: Restraint and Seclusion Usage
Policy Number: # 11008
Effective: 06/01/10

Policy:

...A patient in...restraints retains all his/her rights as outlined in Patient Rights.

The organization will ensure:

1. That the type of restraint used is determined by the situation the restraints is being used to address...

2. That the use of...restraint will be in accordance with the order of a physician or other LIP (licensed independent practitioner) permitted by the state and the hospital to order seclusion and restraint.

Definitions:

The term 'restraint' is defined as "any manual method or physician or mechanical device, materiel attached or adjacent to the patient's body that he or she cannot easily remove that restricts movement or normal access to one's body".

2. Holding a patient and restricting his/her movement also constitutes restraint. According the CMS, "many deaths involved these practices...they may be as potentially dangerous as restraint methods that involve devices".

Practice Standards:

1....A physical restraint is any manual method...that restricts freedom of movement or normal access to one's body...

3. The use of a restraint...must be:
a. Selected only when less restrictive measures have been found...ineffective...
b. In accordance with the order of a physician...to order seclusion or restraint.
4. Orders for use of...restraint must never be written as a standing order or on an as needed basis...
5. The treating physician must be consulted as soon a possible...
6....Must see the patient and evaluated the need for restraint...within one hours after the initiation of this intervention...
11. The orders must be in accordance with a written modification to the patient's plan of care.
14. The condition of the patient who is in a restraint...must be continually assessed, monitored and reevaluated.
15. All staff that had direct patient contact must have ongoing education and training in the proper and safe use of ...restraint...

Documentation:

1. Each episodes of ....restraint required documented information in the patient's medical record...
a. Circumstance leading to pt...restraint use
b. Alternative to...restraint attempted
c. Rational for type of restraint selected
d. Notification of family...
e. Written order for use
f. Behavior criteria for release
g. Informing patient of criteria for release
h. All LIP verbal orders
i. In-person evaluation and reevaluation of patient
j. A 15 minute assessment of patient status
k. Continuous monitoring
l. Debriefing= of patient with staff
m. Injuries sustained, treatment received, death
n. Denial of Rights implemented

Licensed Independent Practitioner Responsibilities:

1. The patient must be evaluated "face-to-face" as appropriateness of ...restraint as an intervention within:
a. One (1) hour of the initiation of the intervention...
2. The physician...will review the physical and psychological status of the patient with staff... provide guidance...in identifying way to help the patient gain control in order to have ...restraint discontinued.
3. The physician...must make a progress note entry...
4....the evaluating Physican...determines there is not need for...restraint, the order must be written to discontinue the intervention. A progress note must be documented to provide clinical support...
5....sign the original order, including time and date....

On 5/7/19 at 10:00 AM, the surveyor provided EI (Employee Identifier) # 1, Chief Executive Officer documentation of required survey items which included a list of patient names on restraint and seclusion since 1/1/19.

At 11:45 AM on 5/7/19 in an interview, EI # 1 reported the facility did not maintain documentation of patients who were restrained or in seclusion and that restraint documentation would be in the patient's MR. EI # 1 reported the facility rarely had to use restraints, but would identify patients names for the survey process.

On 5/8/19 at 10:30 AM, EI # 1 informed the surveyor a list of patients names who had been on restraint/seclusion could not be provided. However, a record requested for review by the survey team, MR # 2, would have documentation of the use of a physical hold by staff during a recent inpatient stay. EI # 1 reported he/she was present during the physical hold, though he/she was not sure of the date of the physical hold.

Record review revealed PI # 2 was admitted to the psychiatric hospital on 12/19/18 with diagnoses including Schizoaffective Disorder, Depressive Type and Suicidal Ideations (SI).

Review of the nurse documentation revealed on 12/23/18 at 6:35 AM, PI # 2 was banging on the window at the nurses station. At 7:00 AM, the nurse documented PI # 2 attempted to enter nurse station, was grabbing staff, attempted to throw chair at window and Geodon 10 mg (milligram) IM (intramuscular) injection was administered. At 9:35 AM, the nurse documented PI # 2 was trying to elope and kick doors in, trying to get into the nurse station, fighting and threatening behavior toward staff. Ativan 2 mg IM orders obtained and Ativan was given.

There was no documentation a restraint/physical hold was performed on 12/2318 or on any other date in the medical record from admission on 12/19/18 to transfer to another psychiatric facility 1/8/19.

In an interview on 5/9/19 at 9:20 AM, EI # 3, Assistant Director of Nurses, Quality Assurance Coordinator, confirmed he/she was aware of the physical hold (restraint) on PI # 2. EI # 3 verified the facility performance improvement documentation submitted failed to contain data for the use of restraint on PI # 2 or any other patient who required restraints/seclusion while hospitalized since January 1, 2019.

The staff failed to follow the facility policy for restraint use, obtain a physician order for the physical hold, document the physical hold in the medical record and update the treatment plan with the use of restraints for PI # 2.

In an interview on 5/9/19 at 12:30 PM, EI # 1 confirmed the staff failed to follow their own policy for the use of restraints.

STAFFING AND DELIVERY OF CARE

Tag No.: A0392

Based on review of medical records (MR), facility policies and procedures, and interviews, it was determine the facility failed to ensure:

a) staff identified and documented the circumstances surrounding a patient injury and performed an assessment of the patient's injury which required an ED (emergency department) visit.

b) staff failed to provide observation, assessment and documentation of a patient's condition which resulted in a severe decline requiring ambulance transport to the emergency room.

This affected 2 of 8 records reviewed which included Patient Identifier (PI) # 3 and PI # 1 and had the potential to affect all patients admitted to the psychiatric hospital.

Findings include:

Policy:Nursing Documentation of Critical Issues
Policy: # 11002
Effective:06.01.10

Policy:

...registered nurse (RN)...provide accurate and complete documentation ...of a potential or actual injury to a patient and does so at the time of occurrence. It is (the) policy that all critical issues be documented clearly and accurately.

Procedure:

1. The RN ...must document in the progress notes regarding any potential or actual injury to a patient and must also document another progress note on this issue prior to leaving at end of shift. The assessment of the patient must be conducted by the nurse and documented.

2. Either by physician's orders or in the nurse's judgement, increased rounds may be made on the patient.

3. A nurse's note should be documented in these cases at the time of the critical issue...

5. These areas of incident requiring more documentation, an initial progress note, and also a note at end of shift are:

a. Patient injury or possible injury;
b. Physical assault to patient...;
c. Emergency room visit;
d. Fall;
e. Adverse drug reaction;
f. Medical changes/difficulties;
g. Other progress notes may be necessary throughout shift as changes occur...

Policy: Behavior Management-Behavior Observation 1:1
Policy # APP 106
Effective: 01/01/2010
Revised: 03/01/2014

Purpose: To ensure the safety and dignity of the resident who requires Behavioral Observation 1:1 by direct care observation.
Policy: Residents requiring a safe environment will be placed on Behavioral Observation 1:1.
Procedure:
1) The physician and sponsor/immediate family will be notified by the Charge nurse when the resident is noted to be a safety risk due to increased confusion and or agitation.

1. PI # 3 was admitted to the Geropsychiatric unit on 1/03/19 at 1:40 AM, transferred from the local ED (emergency department) with diagnoses including Alzheimer Disease with Late Onset, Dementia in Other Diseases Classified Elsewhere Without Behavioral Disturbance.

Review of the Nursing Admission Assessment documentation dated 1/3/19 at 2:00 AM revealed a skin tear to the right forearm. At 5:30 AM, the nurse documented aggressive, assaultative behavior, cursing, yelling at staff, unable to redirect and Geodon intramuscularly was administered. At 10:00 AM, the nurse documented brusing on arms and leg.

Further medical record review revealed on 1/3/19 at 3:15 PM, the nurse documented "...was told in report patient had laceration to right 5th toe that physician needed to evaluate during rounds." At 3:30 PM, the nurse documented the medical doctor (MD) on unit to evaluate laceration to right 5th toes, gave new orders to transfer to ED."

On 1/3/19 at 4:30 PM, the MD completed the history and physical and documented the presence of a 2 centimeter laceration in the web between the fifth toe and the next toe toe on the right foot that will need a stitch or two. The MD ordered transfer to ER (emergency room) for evaluation and treatment of laceration to right 5th toe.

There was no nurse assessment documentation of the laceration, no documentation of how and when PI # 3 sustained the right foot injury which required an ED transport.

In an interview on 5/9/19 at 10:50 AM, Employee Identifier (EI) # 2, Director of Nurses, confirmed the above findings.



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2. Review of PI # 1 who was admitted on 02/13/2019 with diagnosis of Alzheimer's Disease and Dementia.

Review of the MR revealed that on 02/24/2019 at 12:45 AM patient was "restless, climbing out of bed without assistance, disturbing roommate..." Seroquel 50 mg (milligram) was administered.
At 1:40 AM it was documented that PRN (pro re nata) ineffective, patient has increased agitation..." Geodon 10 mg was given intramuscular. At 2:40 AM it was documented that "PRN effective." At 5:15 AM it was documented that "patient slept 5 hours." At 07:46 AM the nurse documented that the patient was "drowsy." At 09:00 AM the nurse documented that the "patient remains drowsy...Certified Registered Nurse Practitioner (CRNP) notified." No nursing assessments or documentation was documented for the next 8 hours. At 5:00 PM the nurse documented "patient...lethargic. Whole face/neck severely edematous. Drooling continuously, non responding except to painful stimuli. Eyes swollen shut. CRNP notified." At 5:40 PM patient was transported to the emergency room by ambulance. After patient was evaluated in the emergency room he was admitted to hospital with altered mental status, urinary tract infection, and dehydration.

In an interview with EI # 2, Director of Nurses on 5/9/19 at 11:00 AM, EI # 2 confirmed that there were no other nurse checks or documentation on the patient between the hours of 9:00 AM and 5:00 PM on 02/24/2019.

PROTECTING PATIENT RECORDS

Tag No.: A0441

Based on observation, facility policy and interview with the Director of Medical Records, it was determined the facility failed to ensure the confidentiality of patient information in the medical records within the medical record department.

Findings include:

Policy: Protection and Availability of Medical Records
Policy Number: 10008
Date: 6/1/10

Policy:
...5. The facility shall safeguard the information in the MR against loss, defacement, tampering or use by unauthorized persons.
6. controlled, locked access to the inactive medical record storage files is maintained.
7. The MR Department shall remain locked at all times when MR personnel are not present...

A tour of the medical record (MR) department was conducted on 5/8/19 at 7:45 AM. The MR department office is located behind the receptionist desk and beside office housing a copy machine used by the facility staff.

During the interview a member of the maintance staff, housekeeping staff, and the receptionist entered the MR department office at different times and moved freely within the office.

Located in the MR department office was a long table with numerous incomplete medical records and a log book of all admissions to the facility located on top of Employee Identifier (EI) # 5, Director of MR, desk.

EI # 5 verbalized the log book contained the following information of all the patients that have been admitted to the facility since opened: the patient's name, MR number, date of birth, sex of patient, admission date, discharge date, pin number, discharge disposition, and payor source.

On 5/8/19 at 8:15 AM, EI # 5 escorted the surveyor to the area that housed the completed MR's, which was not within sight of the MR department office, to tour the area housing the completed MR's.

EI # 5 failed to lock the doors to the MR department office or in any way safeguard the MR department office from unauthorized persons.

An interview was conducted on 5/8/19 at 8:30 AM with EI # 1, Chief Executive Officer, who confirmed the above findings.

DIETS

Tag No.: A0630

Based on review of facility policies and procedures, facility current diet orders and interviews with staff it was determined the facility dietary staff failed to:

1. Ensure the physician ordered diet was provided.

2. Maintain dated menus and substitutions for at least 30 days per the facility policy.

This affected 2 of 2 patient's with a diet order for Limited Concentrated Sweet (NCS) including Patient Identifier (PI) # 8 and Unsampled Patient # 1 and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Policy: Menu Planning & (and) Nutritional Adequacy
Policy Number: 512
Effective: 6/1/10

Purpose: To ensure that menus meet, if not contraindicated, the Recommended dietary Allowances of the Food and Nutrition Board...

Policy: ...Therapeutic diets should be planned, prepared and served with supervision or consultation from a Registered Dietitian. Menus should be designed to meet the nutritional needs of residents in accordance with the attending physician's orders...

Procedure:
...2. The menus shall reflect the portions of each food to be served.
...6. Menu substitutions should be recorded by the Dietary Director directly on the menus with the reason stated for the substitutes, before the substitution is prepared.
7. The Dietary Director should maintain dated menus and substitutions for at least thirty days in an appropriate file.

Policy: Menu Alternates
Policy Number: 406
Effective 6/1/10

Purpose: To ensure residents get complete balanced meals

Policy: An alternate meat or entree should be provided at every meal in the event of personal food preferences or refusals.

Procedure:

...2. Alternates are planned by the Registered Dietitian...
3. When alternates are changed, they should be changed to foods of similar nutritional value....


On 5/8/19 at 9:15 AM a tour of the Dietary Department was conducted with Employee Identifier (EI) # 6, Dietary Manager, and EI # 7, Dietitian.

EI # 6 verbalized during the tour the facility used "two rotating menus" for patient meals. EI # 6 provided the surveyor with the copies of the two menus used by the facility. EI # 7 confirmed the two menus were the only menus used for the facility. EI # 6 verbalized the facility was currently on week 1 of the menu.

Review of the week one and week two menus revealed documentation of a regular diet. There was no documentation of any other diet(s), serving amounts for each of the foods, or alternate foods choices/menu.

Review of the week one menu revealed the following to be served on 5/8/18:
Spaghetti Sauce w/ (with) meat
Spaghetti Noodles
Tossed Salad w/ Dressing
Roll/Butter
Pudding

The surveyor asked EI # 6 for a list/log of the diet(s) currently ordered in the facility.

EI # 6 provided the surveyor with a binder containing separate Dietary-Nursing Communication forms for every patient currently at facility.

Review of the Dietary-Nursing Communication forms revealed the following "Diet Order" choices: Regular, No Add Salt, Limited Concentrated Sweets (NCS), Mechanical Soft (Grd. (ground) meat), Small Servings, Blended, Finger Foods, Double Portion, Large Portions, Other:"

The surveyor asked EI # 6 what would be done if a therapeutic diet was ordered by the physician, since the two menus used by the facility were for a regular diet.

EI # 6 verbalized the facility already did not use salt to cook and for NCS diet the kitchen staff would decrease the amount of food, on the menu, given to the patient. EI # 6 verbalized there was no documentation of how much to decrease (alter) the portion size for different therapeutic diets.

The surveyor asked EI # 6 if there was documentation of weekly menus and any substitutions for 2019. EI # 6 verbalized there was no documentation of the menus used or any substitutions for 2019.

Further review of the Dietary-Nursing Communication forms revealed "diet order" documentation for PI # 8 and unsampled patient #1 as Limited Concentrated Sweets (NCS).

An observation was conducted on 5/8/19 at 11:45 AM to observe the facility lunch service for the patients.

During the observation the following 3 menus were served for a regular diet:

Hamburger with cheese, lettuce, tomato, and pickles
4 oz (ounce) of Potato tots
6 oz of chocolate pudding

4 oz spaghetti noodles
4 oz spaghetti sauce
roll
6 oz salad with a packet of dressing
6 oz chocolate pudding

3 Fried Chicken Fingers
4 oz Potato tots
6 oz chocolate pudding

The following was served to PI #8, who was ordered a NCS diet:
3 Fried Chicken Fingers
4 oz Potato tots
6 oz chocolate pudding

There was no alteration of the serving size for the NCS diet ordered.

The following was served to unsampled patient # 1, who was ordered a NCS diet:
Hamburger with cheese, lettuce, tomato, and pickles
4 oz (ounce) of Potato tots
6 oz of chocolate pudding
There was no alteration of the serving size for the NCS diet ordered.

Following the observation, the surveyor asked EI # 7 if there was documentation of an alternate menu that included the hamburger, Potato tots, and chicken fingers served during the observation. EI # 7 verbalized there was no documentation of the alternate menu served during observation.

An interview was conducted on 5/8/19 at 12:30 PM with EI # 6 who confirmed the above findings.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observation, review of policy and procedure, and interview; it was determined that staff did not perform hand hygiene and gloving as directed per facility policy.

This did affect an unsampled patient, PI # 10 and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: HAND HYGIENE - SANITIZING AGENT
Policy # 451
Effective date 06/01/2010

Purpose: To cleanse hands between patient contact during medication administration and routine care.
Equipment: Antiseptic cleanser such as alcohol gel.
Procedure:

1. Place the container of antiseptic solution on the medication cart in a secure area not accessible to patients.
2. Wash and dry hands thoroughly in preparation for medication administration.
3. Dispense medication into proper containers without touching the medication.
4. Hand medication container to the patient; assist with water, juice or applesauce as necessary.
5. Discard container appropriately.
6. Apply approximately 1 to 3 cc's of antiseptic cleanser into the palm of the hand.
7. Rub hands briskly until hand sanitizing agent has evaporated.
Responsibility: The charge nurse is responsible for the implementation of this policy and procedure.
The clinical director is responsible for the overall compliance of the policy and procedure.

1. An observation of medication pass was conducted on 05/08/2019.
EI # 8 was observed administering medications to MR # 10. While administering the pills via spoon to mouth to PI # 10, EI # 8 dropped one of the pills onto the floor. With his/her gloved hand EI # 8 picked the pill up from the floor and tossed pill in trash receptacle. EI # 8 then continued to give PI # 10 his/her medications via spoon to mouth. EI # 8 failed to removed contaminated glove or perform hand hygiene before continuing to give medications to PI # 10.

An interview with EI # 2 Director of Nurses on 05/09/2019 at 11:00 AM confirmed that hand hygiene should have been performed after picking the pill up from the floor.

INDIVIDUAL COMPREHENSIVE TREATMENT PLAN

Tag No.: B0118

Based on review of medical records (MR), interviews and policy and procedure, and interview it was determined the facility failed to ensure the treatment plan was individualized to meet the needs of the patients in 1 of 1 patients diagnosed with Paranoid Schizophrenia. This affected Patient Identifier (PI) # 7, and had the potential to negatively affect all patients served by facility.

Findings include:

Policy: Master Treatment Planning and Patient Care
Policy Number: 30004
Effective: 6/1/10

Policy: All patient will have a master treatment plan... This plan will be formulated by the professional staff following thorough assessments of the patient.

Procedure:
...2. The treatment plan...will consist of the following:
...b. The team's assessment of the patient's condition
c. A list of specific problems that the team will target in treatment...

3. Assignment to treatment modality as well as frequency and duration of treatment will be in accordance with the terms of the master treatment plan

...5. All documentation will include the focus of treatment, the treatment goal and the patient's behavioral response to treatment efforts.

6. Treatment Plan Update:
a. A formal update of the Master Treatment Plan will be conducted by the team. Target problems will be summarized, progress towards goals will be reviewed, new goals and interventions defined...

1. PI # 7 was admitted to the facility 4/4/19 with a diagnosis of Paranoid Schizophrenia.

The Multidisciplinary Treatment Plan (MTP) documentation revealed the following goals: "Pt will not isolate in room or be observed RIS (Responding to internal stimuli)" and "will attend 2 groups daily with no behaviors for 7 cons. (consecutive) days."

Review of the Patient Care Attendant (PCA) Progress Note(s) revealed the patient obtained a shower on 4/8/19, 4/18/19, and 4/27/19.

Further review of the PCA Progress Note(s) revealed the patient refused to shower on 29 days out of the 32 days reviewed.

Review of the 10 Interdisciplinary Master Treatment Plan's (IMTP) dated 4/9/19 - 5/7/19 revealed no documentation of goal or intervention to address patient not showering.

Review of the Activities Group Note(s) and Social Services Group Note(s) revealed the patient attended a Activities Group session for 10 minutes on 4/19/19.

Further review of the Activities Group Note(s) and Social Services Group Note(s) revealed the patient refused all group therapy sessions 31 days out of the 32 days reviewed.

Review of the 10 IMTP dated 4/9/19 - 5/7/19 revealed no documentation the goal and intervention for "will attend 2 groups daily with no behaviors for 7 cons. days" was discussed and individualized due to patient not meeting the admission goal.

Review of the MR revealed the patient continued to isolate self on 31 days out of 32 days reviewed.

Further review of the 10 IMTP dated 4/9/19 - 5/7/19 revealed no documentation the goal and intervention for "Pt will not isolate in room or be observed RIS" on the MTP was discussed and individualized due to patient not meeting the admission goal.

An interview was conducted on 5/9/19 at 10:05 AM with Employee Identifier # 2, Director of Nursing, who confirmed the above findings.

PLAN INCLUDES SHORT TERM/LONG RANGE GOALS

Tag No.: B0121

Based on review of medical records (MR), policy and procedure and interviews, it was determined in 2 of 3 active records reviewed the treatment team failed to update both short term and long term goals to include new conditions/symptoms. This affected Patient Identifier (PI) # 6 and PI # 7 and had the potential to affect all patients admitted to the psychiatric hospital.

Findings include:

Policy # 3004: Master Treatment Planning and Patient Care
Effective Date: 06.01.10

Policy:

All patients will have master treatment plan developed within five (5) program days of admission. This plan will be formulated by the professional staff following thorough assessments of the patient.

Procedure:

1. The treatment team...led by the psychiatrist...compromised of the Case Manager (...Clinical Social Worker...), the RN (Registered Nurse) and other appropriate staff who interact with the patients.

2. The treatment plan will be signed by all staff...involved in developing the plan and will consist of the following:
a...diagnoses
b. The team's assessment of the patient's problems
c. A list of specific problems...the team will target in treatment
d. A statement regarding the patient's assets and liabilities

3. Assignment to treatment modality as well as frequency and duration of treatment...will be in accordance with the terms of the master treatment plan.

5. Add (Additional) documentation will include the focus of treatment, the treatment goal and the patients behavioral response to treatment efforts.

6. Treatment Plan Update:

a. A formal update of the master treatment plan will be conducted by the team. Target problems will be summarized, progress towards towards goals...reviewed, new goals and interventions defined, as well as...updated.

Observations of care on the Adult Unit were conducted 5/7/19 from 2:20 PM to 3:20 PM.

On 5/7/19 at 3:15 PM, in an interview, Employee Identifier (EI) # 11, RN, reported the treatment team meets twice a week a which time the treatment plan is updated.

1. PI # 6 was admitted to the psychiatric hospital on 4/26/19 with diagnoses including Bipolar Disorder with Psychotic Features.

Review of the Interdisciplinary Master Treatment Plan revealed the master problem list dated 4/26/19 which revealed problem # 1, delusional thoughts. There were 6 additional medical problems documented and tobacco abuse.

Further review of the Interdisciplinary Master Treatment Plan failed to include documentation for the date Initial Treatment Team was conducted with the psychiatrist, nurse, social services, activity therapist and patient. There was no patient signature or reason documented why the patient had not signed the Treatment Plan.

Review of the Interdisciplinary Master Treatment Plan Update dated 5/3/19 revealed treatment progress documentation that MR # 6 continued to be delusional and "endorses anxiety and depression".

There was no update to the master problem list to include depression and anxiety and no treatment interventions and goals for depression and anxiety were added to MR # 6's Master Treatment Plan.

In an interview on 5/9/19 at 10:55 AM, Employee Identifier (EI) # 2, Director of Nurses confirmed the aforementioned findings.


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2. PI # 7 was admitted to the facility 4/4/19 with a diagnosis of Paranoid Schizophrenia.

The Multidisciplinary Treatment Plan (MTP) documentation revealed the following goals "Pt will not isolate in room or be observed RIS (Responding to internal stimuli)" and "will attend 2 groups daily with no behaviors.."

Review of the Patient Care Attendant (PCA) Progress Note(s) revealed the patient refused to shower on 29 days out of the 32 days reviewed.
Review of the Activities Group Note(s) and Social Services Group Note(s) revealed the patient refused all group therapy sessions 31 days out of the 32 days reviewed.
Review of the MR revealed the patient continued to isolate self on 31 days out of 32 days reviewed.

Review of the 10 Interdisciplinary Master Treatment Plan's (IMTP) dated 4/9/19 - 5/7/19 revealed no documentation the patient's goals were updated due to new symptoms, discussed and individualized due to patient not meeting the admission goal.

An interview was conducted on 5/9/19 at 10:05 AM with EI # 2, who confirmed the above findings.

TREATMENT DOCUMENTED TO ASSURE ACTIVE THERAPEUTIC EFFORTS

Tag No.: B0125

Based on medical record (MR) review, and interview, the facility failed to ensure all patients were provided individualized therapeutic treatments for 1 of 1 patients diagnosed with Paranoid Schizophrenia. This affected Patient Identifier (PI) # 7 and had the potential to negatively affect all patients served by facility.

Findings include:

1. PI # 7 was admitted to the facility 4/4/19 with a diagnosis of Paranoid Schizophrenia.

The Multidisciplinary Treatment Plan (MTP) documentation revealed the following Goals and Interventions:
1. Pt (patient) will show no signs of aggressive behaviors with intervention of SW (social worker) will provide ind (individual) therapy for 30 mins (minutes) 1x (one time) weekly
2. Pt will not have any pressured speech with intervention of SW will provide ind therapy for 30 mins 1x weekly...

Review of the MR revealed no documentation of an individual therapy session for:
The week of 4/4/19 through 4/6/19
The week of 4/14/19 through 4/20/19
The week of 4/21/19 through 4/27/19

An interview was conducted on 5/9/19 at 10:05 AM with Employee Identifier # 2, Director of Nursing, who confirmed the above findings.

EP Training Program

Tag No.: E0037

Based on review of Emergency Preparedness (EP) program, review of employee files, and interview with staff it was determined that the facility failed to provide initial and annual training to all of the employees on EP.

This had the potential to negatively affect all of the patients, staff, and visitors of the facility.

Findings include:

Review of the EP program and employee files on 5/8/19 revealed no documentation of the initial or annual training for EP.

The surveyor was provided one Disaster Plan annual orientation sign in sheet dated 4/27/18. Three employees had signed the sheet with no documentation of the title or the employees or what area of the hospital the employees were employed in.

An interview with EI # 2 Director of Nurses (DON) on 5/8/19 at 2:45 PM confirmed that only three employees had been given the in-service and signed the sheet.