HospitalInspections.org

Based on record reviews, observations, hospital policies and interviews the Facility failed to assure:

1. The toll free state hotline number was written and posted.
2. Privacy was provided for patients during psychiatric interviews.
3. Ensure the patient's clothes were returned at discharge.
4. Ensure the consumer rooms were clean.
5. Ensure furniture and fixtures were continually maintained.
6. Ensure restraint logs utilized for quality assurance monitoring.

This had the potential to affect all patients served by the hospital.

Findings include:


Refer to A 118, A 143 and A144 for findings.

Based on observations and interviews with facility staff, it was determined the Facility failed to provide written and posted instructions informing patients and family members of the toll free state hotline number to file a complaint with the State agency. This had the potential to affect all patients and family members.

Findings include:

1. During a tour of the hospital lobby, adult, child and adolescent units on 4/12/11 at 12:45 PM it was noted that the facility did not post the toll free state hot line phone number for patients and family members to call to voice grievances.

2. A review of the hospital admission packet on 4/13/11 at 10:30 AM revealed the telephone number for patients and family members to report grievances to the state was not correct.

An interview with Employee Identifier (EI) #2, Nursing Director, on 4/13/11 at 10:30 AM verified the facility did not have the toll free state hot line phone number available for patients and family members to voice grievances.

Based on observation and interview with a staff nurse it was determined the psychiatrist failed to provide treatment to an adolescent male giving utmost attention to the individual's need for privacy. This had the potential to affect all patient served by the facility.

Findings include:

On 4/14/11 at 8:15 AM, two surveyors observed the Psychiatrist talking with an adolescent boy while standing in line with four other males waiting to go to class. The boy's privacy was not protected and any clinical care issues discussed were not protected from other patients.

On 4/14/11 at 8:30, the surveyors spoke with Employee Identifier # 3, Registered Nurse assigned to the children's section and asked how much time the Psychiatrist spent with the patients. She stated about 3-5 minutes.

Speaking with patients without ensuring their privacy and limited time in conversation with the patient limited the therapeutic care of the patient.

Based on observation and interview with administrative staff it was determined the facility failed to:

1. Ensure the patient's clothes were returned at discharge.
2. Ensure the patients' rooms were clean.
3. Ensure furniture and fixtures were continually maintained.
4. Ensure Quality Assurance reports were utilized for quality monitoring.
5. Ensure the restraint and seclusion logs were completed for each incident.

This had the potential to affect all patients.

Findings include:


On 4/12/11 at 1:00 PM, the surveyors conducted a tour of the third floor of the hospital which housed the adolescent girls, boys and children (12-5 years of age).

The following were observed:

Multiple shower stalls had grey patches on the sides to cover up holes in the shower and a strong musty odor.

Several floor tiles were broken in some of the bathrooms and in two of the dining areas.

One exposed rusted 3 inch screw on the side of the rusted metal screen covering the wall air conditioning unit in the child/male adolescent quiet room.

The mattress had a split in the plastic cover in the quiet room across from room 324.

There was feces on the wall and doors of the toilet area in room 320,a used Band-Aid on the floor and writing on the bathroom walls in room 320.

Air conditioner covers had rusty grates that were dented and damaged with exposed hazardous areas that could harm patients in multiple patient rooms.

The bathroom of room 322 had a rusted area over the toilet and the door to the bathroom was observed to have a lock and hasp. The surveyor asked the Director of Clinical services, who accompanied the surveyors on tour, why the locking apparatus was there and she stated that they were not used and needed to be removed.

In room 326 the surveyor observed a bloody cotton ball in the trash can and other paper items scattered about the floor.

The storage closets on the child/adolescent areas were unlocked, which revealed numerous black trash bags, back packs, tote bags and other luggage in disarray. Some of the bags were labeled with tape but others were not. The Director of Clinical Services stated that sometimes the patients left without their clothes and that they tried to send them to them. There were 16 unlabeled bags/containers in the storage closet on the children and adolescent area.

An initial tour of the adult/ICU unit conducted on 4/12/11 at 12:40 AM revealed the following:

The quiet room (207) had a rusted metal screen cover over the wall air conditioning unit.

Room 205 did not have a hand washing sink available.

Room 202 had mini-blinds in need of repair.

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Facility Policy: Quality Assurance Reporting # EC.005 Effective Date 7/1/1994

" Purpose: To provide a mechanism for reporting hospital occurrences related to patient/employee safety

...A Quality Assurance Report (Incident Reports) will be completed and forwarded to the Risk Manager for follow-up.

The following occurrences should warrant completion of an Quality Assurance Report, but is not inclusive:

1. Patient injury, patient abuse, or patient emergency "

Facility Policy: Restraints and Seclusions

" Purpose:
(name of management group)...as an organization is committed to preventing, reducing, and striving to eliminate the use of restraint and seclusion. All patients have the right to be free from restraints and seclusion and staff are committed and trained to therapeutically deescalate patients enhancing their ability to use coping skills which enable them to re-gain self-control.
Our leadership is committed to create an environment that minimizes circumstances that give rise to restraint and seclusion use and that maximizes safety for all patients and staff. We our committed to allocating sufficient resources, providing initial and ongoing education, and integrating the use of restraints and seclusion into our performance improvement activities.

Section Nine: Organizational Oversight and Performance Improvement.

Data on the use of restraint and seclusion will be collected to monitor and improve any processes that involve risks or may result in sentinel events. Data will allow leadership to monthly analyze need for process redesign, opportunities for reducing the rate and increasing the safety of restraint and seclusion use. Each episode of restraint and seclusion will be logged."


1. MR # 1 was admitted to the facility 1/19/11 with a diagnosis of Bipolar Disorder not otherwise specified and Impulse Disorder not otherwise specified.

Review of MR # 1's medical record revealed documentation the patient was placed in restraints multiple times between 3/2/11 and 4/3/11.

Review of the facility's Restraint log revealed no documentation of MR # 1 being placed in restraints 3/2/11, 3/3/11, 3/4/11 , 3/7/11, 3/11/11, 3/13/11 and 3/15/11.

This information was confirmed 4/14/11 at 9:00 AM by Employee Identifier # 1, the Director of Clinical Services.

2. MR # 2 was admitted to the facility 3/14/11 with a diagnosis of Bipolar Disorder,not otherwise specified and Impulse Control Disorder, not otherwise specified.

A review of the medical record revealed MR # 2 swallowed a staple 3/29/11 and was transported to the local Emergency room for evaluation.

A review of the Quality Assurance reports 4/13/11 failed to reveal a report regarding the incident or any investigation into the incident.

On 4/14/11 a Quality Assurance report was presented to the surveyor with the explanation that it was on the Nurse Manager's desk.
The surveyor asked the Nurse Manager if there was any other documentation or investigation into the patient swallowing a staple. A brief documentation was submitted to the surveyor from the Nurse Manager, without a date regarding speaking to the teacher about the use of staples. When asked the teacher informed EI # 1 on 4/14/11 at 11:00 AM the paper was presented to him that morning for a signature.

Review of the facility's Quality Assurance Reports revealed no documentation of the above incident being completed on a Quality Assurance Report that could have been reviewed to prevent this type of incident from occurring again.




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3. Medical Record (MR) # 7 was admitted to the hospital on 2/14/11 with diagnoses including Major Depressive Disorder.

Review of the Restraint/Seclusion Protocol dated 3/4/11 revealed documentation the patient was trying to harm self with a pencil and resulted in the use of a five point leather restraint.

Review of the facility's Quality Assurance Reports revealed no documentation of the above incident being completed on a Quality Assurance Report that should have been reviewed to prevent this type of incident from occurring again.

Review of the Restraint/Seclusion Protocol dated 3/28/11 revealed documentation the patient was trying to harm self with a straightened paper clip and resulted in the use of a five point leather restraint.

Review of the facility's Quality Assurance Reports revealed no documentation of the above incident being completed on a Quality Assurance Report that could have been reviewed to prevent this type of incident from occurring again.

Review of the Restraint/Seclusion Protocol dated 3/14/11 revealed documentation the patient was placed in 5 point leather restraints due to an attempt to harm self.

Review of the Restraint and Seclusion Log revealed no documentation of the incident of restraint dated 3/14/11.

An interview was conducted on 4/14/11 with Employee Identifier (EI) # 1, the Clinical Director who verified there was no documentation of the above incidents dated 3/4/11 and 3/28/11 were completed on a Quality Assurance Report. The surveyor then asked EI # 1, if the restraint incident dated 3/14/11 was documented in the restraint log. The response was, " No."

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.

Findings include:

Refer to Life Safety Code violations.

Based on facility policy, review of personnel files and interview with staff, the facility failed to ensure the policy for Hepatitis B Vaccination for employees was followed. This had the potential to affect all staff.

Findings include:

Policy titled Infection Control Plan included, " Hepatitis B Vaccination. The Hepatitis B Vaccination series is available at no cost after training and within 10 days of initial assignment to employees identified in the exposure determination section of this plan. Vaccination is encouraged unless: 1) documentation exists that the employee has previously received the series, 2) antibody testing reveals that the employee is immune, or 3) medical evaluation shows that vaccination is contraindicated .....Employees, contract workers, and students who may be exposed to blood/body fluids will be offered the Hepatitis B vaccine ...Vaccine will be provided by the Infection Control/Employee Health office."

Review of the health personnel files revealed six employees, Employee Identifier numbers 4, 5, 6, 7, 8 and 9, meeting exposure criteria and with hire dates greater than four months, had signed a request for the Hepatitis B vaccination series.

An interview on 4/14/11 at 11:15 AM with Employee Identifier # 1, Clinical Director, confirmed the Hepatitis vaccine had not been administered to the six employees who requested it.

Based on medical record review, review of the facility's policies and procedures and interview with the staff, it was determined the facility failed to ensure the treatment team revised the patients' treatment plans to include revision, resolutions or progress toward objectives in 4 of 13 records reviewed. This affected Medical Record (MR) #2, # 6, # 1 and # 3.

Findings include:

Facility Policy: Master Treatment Plan (MTP) # PC.013 revised 3/11/99

Policy:

To provide a comprehensive individualized and multidisciplinary plan of treatment for each patient.

Procedure:

4. The MTP will be completed and reviewed/revised by the treatment team according to the following schedule:

- completed within five days of admission

- reviewed every seven days of each patients' admission until discharge for each patient.

note: Revisions may be made anytime during the course of treatment but must be made at these times...

6. Each discipline must sign the MTP and weekly update review signatures must include credentials.

7. MTP will be completed within five days of admission and will contain behavioral and measurable objectives and include target dates and dates of resolution.

8. A primary counselor will be assigned to each patient at time of admission. It is the responsibility of the counselor to ensure the MTP is initiated, completed and updated by each discipline involved in the patient's care.

1. MR # 6 was admitted to the hospital on 3/6/11 with diagnoses including Bipolar with Suicidal Ideation without Plan. Review of the treatment Plan dated 3/6/11 revealed the following objectives:

1. ...(the patient's name) will report on improved mood within 3 - 7 days, she/he will verbalize at least 2 new coping skills, and she/he will avoid harming her/himself or other while at ...(the hospital). The target date was 3/14/11.

2. ...(the patient's name) will have a decrease in emotional outburst while at ...(the hospital). The target date was 3/25/11.

3. No documentation of what the objectives was with an intervention which included- MD (Medical Doctor) will Rx (prescribe) with mood stability medications to alleviate distress and see daily to evaluate response. The target date was 3/13/11.


There was no documentation on the treatment plan if the objectives were revised, resolved, or if any progress toward the objectives were obtained.

There was no documentation the treatment plan was reviewed in seven days of the patients admission or at discharge.

An interview was conducted on 4/14/11 at 10:15 Am with Employee Identifier (EI) # 1, the Clinical Director.






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2. MR # 1 was admitted to the facility 1/19/11 with a diagnosis of Bipolar Disorder not otherwise specified and Impulse Disorder not otherwise specified.

The treatment plan was established 1/20/11. The first goal documented on 1/20/11 was, " Pt (patient) and staff will remain free from harm while at MVH (hospital). " The target date was for 2/3/11.
The second goal was, " Pt will process emotions and improve her coping skills." The target date was for 1/30/11.
On 1/24/11 the third goal was documented, " Client will attend activity therapy..." The target date was for 2/3/11.
On 2/24/11 a fourth goal was documented, " ... will attain sleep pattern/hrs (hours) R/T (related to) rest without greater than 9-10 hours of sleep per day." The target date was for 3/2/11.

The medical record had been thinned 3/3/11. The medical record reviewed included 6 forms titled treatment plan update reviewed and approved. One of the forms was dated 3/8/11 and did not include a signature of participation from the Therapeutic Educator or Staff Nurse. One of the forms was dated 3/15/11 and did not include a signature of participation from the Therapeutic Educator, Activity Therapist or Staff Nurse.
The other 4 forms did not have dates on them and no signature from the Therapeutic Educator or Staff Nurse on different forms.

There was no documentation if the patient had made progress toward meeting goals, or documentation of the review. There was no documentation to continue with the current goals and approaches; or to revise the treatment plan to increase the possibility of a successful treatment outcome.

In response to written questions regarding the treatment team updates and review or changes, Employee Identifier (EI) # 1, the Clinical Director, confirmed on 4/14/11 at 8:35 AM, that it was not done.

3. MR # 2 was admitted to the facility on 3/14/11 with diagnosis of Bipolar Disorder not otherwise specified and Impulse Disorder not otherwise specified.

The treatment plan was established 3/14/11. The first goal documented on 3/13/11 ( wrong date) was, " Pt and staff will remain free from harm while at MVH (hospital)." The target date was for 4/5/11. The second goal was, " Pt will be free of anger and aggressive behavior AEB (as evidenced by) 5 consecutive days free of outburst and possess positive attitude." The target date was for 3/21/11. On 3/21/11 the third goal was documented, " Client will attend activity therapy..." The target date was for 3/21/11.

The initial treatment plan failed to include the Teacher according to the signatures on the form.

The medical record reviewed included 3 forms titled treatment plan update reviewed and approved. One of the forms was dated 3/15/11 and did not include a signature of participation from the Therapeutic Educator. One of the forms was dated 3/29/11 and did not include a signature of participation from the Therapeutic Educator.
The other form did not have a date on it and was not signed by the Therapeutic Educator.

There was no documentation if the patient had made progress toward meeting goals, or documentation of the review. There was no documentation to continue with the current goals and approaches; or to revise the treatment plan to increase the possibility of a successful treatment outcome.

In response to written questions regarding the treatment team updates and review or changes, Employee Identifier (EI) # 1, the Clinical Director, confirmed on 4/14/11 at 8:35 AM, that it was not done.

4. MR # 3 was admitted to the facility 3/21/11 with Bipolar Disorder.

The treatment plan was established 3/22/11. The first goal documented on 3/21/11 was, " Pt will be free of violence directed toward others while being treated at MVH ( hospital). The target date was for 4/15/11. On 3/22/11 the second goal was documented, " Client will attend activity therapy..." The target date was for 4/15/11. The third goal was, " Pt will have a positive attitude and will maintain good self control AEB 5 consecutive days with bright affect and good decision making skills." The target date was for 4/2/11.

The medical record reviewed included 4 forms titled treatment plan update reviewed and approved. One of the forms was not dated and only had a signature from the Therapeutic Educator and a Staff Nurse. One of the forms was dated 3/29/11 and did not include a signature of participation from the Therapeutic Educator or Psychiatrist. One of the forms was dated 4/5/11 and did not include a signature of participation from the Psychiatrist.

There was no documentation if the patient had made progress toward meeting goals, or documentation of the review. There was no documentation to continue with the current goals and approaches; or to revise the treatment plan to increase the possibility of a successful treatment outcome.

In response to written questions regarding the treatment team updates and review or changes, Employee Identifier (EI) # 1, the Clinical Director, confirmed on 4/14/11 at 8:35 AM, that it was not done.