HospitalInspections.org

Based on document review and interview, the facility failed to ensure the nursing staff followed there policies and procedures related to developing a client's plan of care/treatment plan with appropriate interventions for eight (8) of thirty (30) medical records (MR's) reviewed. (Client MR's # 3, # 4, # 11, # 12, # 13, # 14, # 15 and # 17)

Findings include:

1. Review of the hospital policy titled, "Written Program Description", policy Stat ID 5377113, indicated every client admitted to the inpatient care center (ICC) has an individual plan of care generated. Upon admission, all clients are assessed by nursing staff and an individual plan of care "is initiated" based on the "needs and desires of the client served" and his/her integration back into the community. A "personal safety plan is conducted which includes interventions". Client specific problems are addressed and both short and long term goals are identified "as well as the interventions needed by staff to aid the client" in achieving his/her goals. This policy was last revised in 06/2016.

2. Review of the hospital policy titled, "Suicide Assessment and Tiered Intervention", policy number 4.04, the physician will issue an "order defining the level of suicide precautions" appropriate for the client. The suicide interventions for a patient ordered as "High" level would include "disposable scrubs to wear at all times" and a revised diet order to "safe tray". This policy was last revised on 02/08/2019.

3. Review of the MR's indicated the following:
A. The physician order dated 08/31/2019 indicated Client # 3's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the interventions related to disposable scrubs and a safe tray.
B. The physician order dated 09/12/2019 indicated Client # 4's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the interventions related to disposable scrubs and a safe tray.
C. The physician order dated 09/17/2019 indicated Client # 11's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the intervention related to disposable scrubs.
D. The physician order dated 09/26/2019 indicated Client # 12's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the interventions related to disposable scrubs and a safe tray.
E. The physician order dated 09/26/2019 indicated Client # 13's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the interventions related to disposable scrubs and a safe tray.
F. The physician order dated 07/10/2019 indicated Client # 14's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the interventions related to disposable scrubs and a safe tray.
G. The physician order dated 08/14/2019 indicated Client # 15's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the interventions related to disposable scrubs and a safe tray.
H. The physician order dated 07/28/2019 indicated Client # 17's Suicide Precaution Level to be "High". The plan of care/treatment plan indicated one of the client's goals to be "Suicidality" but lacked the interventions related to disposable scrubs and a safe tray.

4. In interview on 11/19/2019 at approximately 3:25 pm with staff member NS # 2 (Nursing Supervisor/Infection Control Nurse), confirmed the suicide interventions should be documented on the treatment plan/plan of care. At 3:40 pm NS # 2 confirmed the policy number for Suicide Assessment and Tiered Interventions was 4.04.

Based on observation and interview, the facility failed to ensure 2 of 2 hazardous areas such as combustible storage rooms over 50 square feet were protected in accordance with LSC Section 19.3.2.1, failed to maintain protection of 1 of 8 corridor walls in accordance of 18.3.6.2. LSC 18.3.6.2, Construction of Corridor Walls, failed to protect 8 of 8 inpatient rooms in accordance with LSC 19.3.6.3.5 which requires that doors shall be provided with a means for keeping the door closed and withstand a force of 5 pounds, failed to ensure 1 of 2 sets of smoke barrier doors on the second floor would restrict the movement of smoke for at least 20 minutes and failed to conduct 1 of 12 quarterly shift fire drills during the most recent 12 month time period (see tag 709).


The cumulative effect of these systemic problems resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure 2 of 2 hazardous areas such as combustible storage rooms over 50 square feet were protected in accordance with LSC Section 19.3.2.1. Section 19.3.2.1 states that any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire-resistive rating or shall be provided with an automatic extinguishing system in accordance with Section 8.7.1. Where protected by sprinklers, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4, failed to maintain protection of 1 of 8 corridor walls in accordance of 18.3.6.2. LSC 18.3.6.2, Construction of Corridor Walls, requires corridor walls shall form a barrier to limit the transfer of smoke, failed to protect 8 of 8 inpatient rooms in accordance with LSC 19.3.6.3.5 which requires that doors shall be provided with a means for keeping the door closed and withstand a force of 5 pounds, failed to ensure 1 of 2 sets of smoke barrier doors on the second floor would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.8 requires that doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke and failed to conduct 1 of 12 quarterly shift fire drills during the most recent 12 month time period.

Findings include:

During a tour with the Director of Facility Management on 11/18/19 from 2:10 p.m. to 3:45 p.m. the following conditions were found:
a) At 2:26 p.m. the "Paper Storage" room had multiple cardboard boxes, stacks of paper, paper supplies, and fabric stored along the wall. The door to the room opened to the corridor and was not automatic closing.
b) At 2:34 p.m. the "Marketing Storage" room had combustible storage. The door to the room opened to the corridor and was not automatic closing.
c) At 2:37 p.m. the "Accounting Storage" room had multiple cardboard boxes, storage binders, and other paper documentation. The door to the room opened to the corridor and was not automatic closing.

Based on interview at the time of each observation, the Director of Facility Management agreed that the rooms contained combustible storage and were not properly protected.

Based on observation with the Director of Facilities Management on 12/07/16 at 2:34 p.m., the wall between the room and the corridor had two pass-through vents, approximately 4 inches by 8 inches in size. Based on interview at the time of observation, the Director of Facilities Management agreed the corridor wall would not limit the transfer of smoke.

During a facility tour with the Director of Facility Management on 11/18/19 at 3:31 p.m. it was found that the 8 inpatient rooms of the Inpatient Care Center did not positively latch into the door frame when closed. Based on a clinical needs exception, the doors are secured with deadbolts. Based on a subsequent review of the facility "Internal Disaster Plan", the plan addressed closing doors, however did not ensure the in-patient doors, which are not positive latching, would remain closed during a fire. Based on interview at the time of observation, the Director of Facility Management agreed that the doors did not positively latch.

During a tour with the Director of Facility Management on 11/18/19 from 2:10 p.m. to 3:45 p.m. the second floor east smoke barrier door had been removed. Based on interview at the time of observation, the Director of Facility Management agreed that the smoke barrier door had been removed.

During record review with the Director of Facility Management on 11/18/19 from 9:30 a.m. to 2:10 p.m. the facility provided fire drill documentation, however it was incomplete. The facility was unable to provide documentation of a fire drill for the first and third shift for the second quarter of 2019; nor the second and third shifts for the third quarter of 2019. Based on interview at the time of record review, the Director of Facility Management acknowledged the missing fire drills.

Based on record review and interview, the facility failed to ensure 1 of 8 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors.

Based on record review of titled "Emergency Drill Log" with the Director of Facility Management on 11/18/19 from 9:30 a.m. to 2:10 p.m., the fire drill for the first shift, first quarter, did not document the transmission of signal. Based on interview at the time of record review, the Director of Facility Management confirmed that the transmission of the alarm was not documented.

Based on document review and interview, the facility failed to ensure infection control practices related to following CDC guidelines were followed in five (5) instances.

Findings include:

1. Review of 2017 CDC (Centers for Disease Control and Prevention) article "Healthcare Personnel Vaccination Recommendations" from www.immunize.org, indicated it was "recommended that all healthcare personnel (HCP) be immune to varicella". Evidence of immunity in HCP includes "documentation of two (2) doses of varicella vaccine" and/or "immunity, laboratory confirmation of disease".

2. Review of CDC document titled, "Immunization of Health-Care Personnel Recommendations" of ACIP (Advisory Committee on Immunization Practices) Recommendations and Reports/Volume 60/Number 7 dated November 25, 2011 indicated "...Measles, mumps, and rubella (MMR) history of disease is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP; laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. History of disease has never been considered adequate evidence of immunity for rubella. Specifically, guidance is provided for 2 doses of MMR for measles and mumps protection and 1 dose of MMR for rubella protection".

3. Review of the health files on 11/19/2019 indicated the following personnel lacked appropriate documentation related to evidence of immunity for MMR and Varicella:
A. Staff member NS # 1 (Registered Nurse-RN).
B. Staff member NS # 3 (RN).
C. Staff member T # 1 (Psychiatric Technician).
D. Staff member SW # 1 (Licensed Clinical Social Worker-LCSW).
E. Staff member LH # 1 (Lead Housekeeper).

4. In interview on 11/19/2019 at 9:20 am with administrative staff member A # 5 (Human Resource Specialist), confirmed the facility does not require the personnel staff to bring in their immunization for MMR and/or Varicella nor do they run titers.

5. In interview on 11/19/2019 at 3:00 pm with NS # 2 (Nursing Supervisor/Infection Control Nurse), confirmed they followed the CDC guidelines.

Based on record review and interview, the facility failed to provide social work assessments that met social work standards, including: 1) accurate data regarding suicidality; and 2) conclusions and recommendations that described anticipated social work roles in treatment and/or discharge planning for six (6) of six (6) active sample patients (1, 2, 3, 4, 5, and 6). This deficiency hindered social work treatment services and a lack of social work input to the treatment team.

Findings include:

A. Record Review:

1. Patient 1's social work assessment (dated 11/14/19) noted in the data portion that the patient exhibited no suicide ideation or intent. However, the primary complaint stated, the patient "wanted the officers to shoot [the patient]." In addition, there were no recommendations for inpatient treatment by the social worker.

2. Patient 2's social work assessment (dated 11/16/19) noted in the data portion that the patient exhibited no suicide ideation or intent. However, the primary complaint stated, "I had suicide thoughts and I self-harmed pretty bad." In addition, there were no recommendations for inpatient treatment by the social worker.

3. Patient 3's social work assessment (dated 11/17/19) had no recommendations for inpatient treatment by the social worker. In addition, there were no recommendations for discharge placement or follow-up.

4. Patient 4's social work assessment (dated 11/17/19) had no recommendations for inpatient treatment by the social worker.

5. Patient 5's social work assessment (dated 11/17/19) noted in the data portion that the patient exhibited no suicide ideation or intent despite severe drug abuse and the disclosure that the patient "took penicillin to induce an allergic reaction that may result in death at the age of 16." In addition, there were no recommendations for inpatient treatment by the social worker.

6. Patient 6's social work assessment (dated 11/18/19) noted in the data portion that the patient exhibited no suicide ideation or intent despite the primary complaint stating the patient was "experiencing suicidal thought and making a suicidal gesture." In addition, there were no recommendations for inpatient treatment by the social worker.

B. Interview:

On 11/19/19 the Director of Clinical Services was interviewed at 12:15p.m. and stated, "Yes, I see what you mean about the data portion. We will have to work on that and the recommendations for inpatient treatment and discharge planning."

Based on record review and interview, the treatment goals in the Master Treatment Plans (MTPs) failed to correlate with the identified problem and/or were stated in non-measurable terms for six (6) of six (6) active sample patients (1, 2, 3, 4, 5 and 6). This failure hinders the treatment team's ability to individualize treatment and to measure change in the patient consequent to treatment interventions.

Findings include:

A. Record Review:

1. Patient 1: MTP initiated on 11/13/19.

For problem, "Suicidality," a non-measurable goal was stated as "[Patient] will develop 3 new alternatives to cope with conditions that contribute to suicidal thoughts/behavior."

2. Patient 2: MTP initiated on 11/15/19.

For problem, "Suicidality," a non-measurable goal was stated as "[Patient] will develop 3 new alternatives to cope with conditions that contribute to suicidal thoughts/self-harming behavior."

3. Patient 3: MTP initiated on 11/15/19.

For problem, "Thought Disorder," the only goal was stated as, "[Patient] will sleep 6-8 hours per night, attend 100% of groups and will eat 100% of each meal daily." This goal did not address the patient's paranoia and hallucinations.

4. Patient 4: MTP initiated on 11/15/19.

For problem, "Suicidality," non-measurable goals were stated as " ...will increase [his/her] ability to manage depression" and "[Patient] will learn 2 ways to reframe [his/her] thoughts/views regarding [his/her] life circumstances by discharge."

5. Patient 5: MTP initiated on 11/15/19.

For problem, "Suicidality," non-measurable goals were stated as "[Patient] will have 0 thoughts of suicide by the time of discharge from the ICC (Inpatient Care Center)" and "[Patient] will learn and practice 3 positive affirmations to use daily, by discharge."

6. Patient 6: MTP initiated on 11/16/19.

For problem, "Suicidality," the non-measurable goal was stated as, "Client will identify 3 triggers to anxiety and will implement 5 coping skills." This goal does not describe the triggers or coping skills.

B. Interview:

1. The Vice President for Clinical Services was interviewed on 11/19/19 at 12:15 p.m. and concurred that the goals were not measurable or individualized.

2. The Medical Director was interviewed on 11/19/19 at 9:30 a.m. and stated, "I agree that the goals are not individualized or measurable."

Based on record review and interview, there was failure to adequately develop and document Master Treatment Plans (MTPs) that included individualized treatment interventions with specific focus based on the needs of six (6) of six (6) active sample patients (1, 2, 3, 4, 5 and 6). Some interventions were generic disciple functions or were repeated for several patients without specifics based on individual patient findings. For some of the patients nursing interventions to address risk behaviors of suicide and psychotic behaviors were not present in the treatment plans. This deficiency results in failure to provide a basis for accurate implementation and evaluation of treatment provided, and to plan revisions based on individual patient needs and findings.

Findings include:

A. Record Review:

1. Patient 1: MTP initiated on 11/13/19.

For problem, "Suicidality/Mood," a SW/Rehabilitation intervention was stated as "Provide Experiential Therapy up to 6x/we [week] to develop and practice 2 coping skills to stabilize mood and functioning, and transform suicidal thoughts to future-oriented goals." This exact intervention was also in the treatment plans for Patients 4, 5 and 6; additional information regarding type of coping skills or specific focus of treatment based on the specific patient needs was not noted.

A generic nursing intervention was stated as "Encourage 1:1 every shift for [Patient] being active in the milieu, participation in unit groups appropriately and practicing coping skills." Even though this patient was suicidal, there were no nursing interventions to direct nursing personnel in the safety of this patient in the clinical area.

2. Patient 2: MTP initiated on 11/15/19.

For the problem, "Suicidality," generic interventions were:

A Nursing intervention stated as "Encourage [patient] 1:1 every shift to be active in milieu, participating in unit groups and practicing coping skills."

A Social Work intervention was stated as "[Patient] will be invited to Process groups daily during which time [patient] will be prompted to discuss relationship issues impacting mood and functioning, provide feedback to peers and respond to feedback from peers." This exact intervention was also in the treatment plans for Patients 4, 5 and 6; additional information regarding relationship issue(s) was not noted.

There were no interventions for experiential therapy conducted by Social Work/Rehabilitation Therapy.

3. Patient 3: MTP initiated on 11/15/19.

For the problem, "Thought Disorder," generic interventions were:

A Social Work intervention stated as "[Patient] will be invited to Process Group daily during which time she will be prompted to maintain focus and direction in the present moment and will be provided with redirection as needed."

A SW/Rehabilitation intervention was "Provide Experiential Therapy up to 6x/week to develop and practice 2 coping skills to improve thought process and focus on the present moment."

4. Patient 4: MTP initiated on 11/15/19.

For problem, "Suicidality/Mood," a SW/Rehabilitation intervention was stated as "Provide Experiential Therapy up to 6x/we [week] to develop and practice 2 coping skills to stabilize mood and functioning, and transform suicidal thoughts to future-oriented goals." This exact intervention was also in the treatment plans for Patients 1, 5 and 6; additional information regarding type of coping skills or specific focus of treatment based on the specific patient needs was not noted.

A generic nursing intervention was stated as "Encourage 1:1 every shift for [Patient] being active in the milieu, participation in unit groups appropriately and practicing coping skills." Even though this patient was suicidal, there were no nursing interventions to direct nursing personnel in the safety of this patient in the clinical area.

A Social Work intervention was stated as "[Patient] will be invited to Process group daily during which time [s/he] will be prompted to discuss relationship issues impacting [his/her] mood and functioning, provide feedback to [his/her] peers ad respond to feedback from peers." This exact intervention was also in the treatment plans for Patients 2, 5 and 6; additional information regarding relationship issue(s) was not noted.

5. Patient 5: MTP initiated on 11/15/19.

For problem, "Suicidality," a SW/Rehabilitation intervention was stated as "Provide Experiential Therapy up to 6x/we [week] to develop and practice 2 coping skills to stabilize mood and functioning, and transform suicidal thoughts to future-oriented goals." This exact intervention was also in the treatment plans for Patients 1, 4 and 6; additional information regarding type of coping skills or specific focus of treatment based on the specific patient needs was not noted.

A generic nursing intervention was stated as "Encourage 1:1 every shift for [Patient] being active in the milieu, participation in unit groups and practicing coping skills." Even though this patient was suicidal, there were no nursing interventions to direct nursing personnel in the safety of this patient in the clinical area.

A Social Work intervention was stated as "[Patient] will be invited to Process group daily during which time [s/he] will be prompted to discuss relationship issues impacting [his/her] mood and functioning, provide feedback to [his/her] peers ad respond to feedback from peers." This exact intervention was also in the treatment plans for Patients 2, 4 and 6; additional information regarding relationship issue(s) was not noted.

6. Patient 6: MTP initiated on 11/16/19.

For problem, "Suicidality," generic interventions were:

A Nursing intervention was stated as "Encourage 1:1 every shift for [patient] being active in the milieu, participating in unit groups and practicing coping skills. Medication education 1:1 as needed to learn and discuss Cymbalta for treatment of [patient's] mood symptoms."

A Social Work intervention was stated as "[Patient] will be invited to Process groups daily during which time [patient] will be prompted to discuss relationship issues impacting mood and functioning, provide feedback to peers and respond to feedback from peers." This exact intervention was also in the treatment plans for Patients 2, 4 and 5; additional information regarding relationship issue(s) was not noted.

A Social Work/Rehabilitation Therapy intervention was stated as "Provide Experiential Therapy up to 6x/we [week] to develop and practice 2 coping skills to stabilize mood and functioning, and transform suicidal thoughts to future-oriented goals." This exact intervention was also in the treatment plans for Patients 1, 4 and 5; additional information regarding type of coping skills or specific focus of treatment based on the specific patient needs was not noted.

B. Interviews

1. The Vice President for Clinical Services was interviewed on 11/19/19 at 12:15 p.m. and concurred that the social work interventions tended to be generic and were identical in some cases.

2. The Director of Nursing was interviewed on 11/19/19 at 1:30 p.m. and verified the findings related to nursing interventions on the treatment plans.