HospitalInspections.org

Condition Not Met

Based on observations, record review and interviews, the Hospital failed to have an effective Governing Body legally responsible for the conduct of the hospital as an institution. Findings include:

1. The Hospital failed to assure that for one sampled patient (#5) and three nonsampled patients (NS (A), NS (H) and NS (I) ), the patient's assessed care needs were evaluated in order to anticipate potential emergency care scenarios and develop the policies, procedures, and staffing that would enable the Hospital to provide safe and adequate initial treatment of an emergency conditions that could arise and plan emergency services accordingly.
a. The Hospital policy for Emergency Response, last reviewed and updated on 3/31/09, for medical emergencies, indicated that for a Code Blue (medical emergency of any kind) all available physicians will respond.
Review of Attachment A of the Emergency Response is a list of recommended medical interventions. It states that intravenous (IV) lines will not be placed, therefore, IV medications cannot be administered. Oral airways, if indicated, will be placed by the physician. Oxygen (up to 2 liters may be started by the nurse). The attachment lists emergency conditions with common interventions available to staff, stating it is not exhaustive or prescriptive.
The list include cardiac arrest with an intervention of ( automatic external defibrillator)AED: hypoglycemia with an intervention of oral glucose for a patient who can swallow or intramuscular (IM) Glucagon; asthma with an intervention of oxygen and Albuterol inhaler: angina with an intervention of Nitroglycerin; anaphylaxis/laryngospasm with an intervention of Epipen injection or Benadryl IM: shock with an interventions of Trendelenburg position (feet elevated) and Status epilepticus ( prolonged tonic-clonic seizure) with an intervention of airway management and oxygen.
The list failed to address choking, aspiration and airway obstruction with recommended interventions.
Review of Hospital's CODE BLUE ( Medical emergencies) Information form, reviewed and revised on 3/3/09, under part III interventions, lists "aid given" which includes rescue breathing, Ambu bag, oxygen, suction, CPR and AED. There was no suction equipment available in the Hospital.
b. Lack of emergency services planning lead to an emergency condition of airway obstruction for NS (A) during a cardiac arrest, on 5/18/12, where the patient could not be ventilated, for approximately 24 minutes, as observed and timed by surveyor, during resuscitation efforts, until EMS arrived and provided airway suctioning prior to intubation.
c. Review of Medical Staff Meeting Minutes from 3/16/12, indicated medical staff had identified NS (H) as a choking risk with a swallowing disorder. On 4/6/12, after the patient had a radiology appointment, the Medical staff notes indicated the patient was an "aspiration risk." There were no other actions identified to ensure safety other than to continue 1:1 supervision with eating.
d. Patient #5 had choking episode while eating with 1:1 supervision on 7/22/11. Heimlich maneuver able to clear airway. Using the assessment done on 10/14/11, by Registered Dietitian (RD) indicated the patient remains high risk for choking, holds food in mouth and had poor dentition. Medical staff minutes indicated no further action taken to ensure safety and the plan was to continue 1:1 and supervision with eating.
e. Medical Staff Meeting Minutes also indicated NS (H) was also assessed as high risk for choking. The plan was to continue ground diet and supervision with eating. There were no other actions identified to ensure safety other than to continue supervision with eating.

See A-0093

2. The Governing Body failed to determine, in accordance with State law, that Physician Assistants (PA), were an eligible category of practitioners for appointment to the medical staff, prior to hiring a PA.

There is not a privileged clinical category for Physician Assistants in Appendix A of the Medical Staff Bylaws that describes licensure and practice for PA.

See A-0045

3. The Governing Body failed to ensure that the contracted Food and Nutrition Vendor provided services in a safe and effective manner.

Review of the contract. observations and interview with the Food Service Director (FSD) and Dietitian (RD) on 5/15/2012 at 9:30 A.M. indicated that the Hospital failed to:
- For 5 of 7 Food Service Employees the Hospital failed to screen the employees for TB as required per Vendor Contract and Hospital Policy. (Employees #1, 3, 4, 5 and #6).
-The Hospital's Contract for Food Service read that "the Vendor shall maintain the kitchen and cafeteria facility area in a presentable condition at all times. This includes counters, tables, serving areas, cabinets and storage areas." Review of the Hospital's monthly Infection Prevention Surveillance Reports for 1/26/12, 2/29/12 and 3/30/12 identified 12 areas of concern related to sanitation of equipment and utensils, dry storage and cafeteria service which remain uncorrected.
-The Hospital's Contract for Food Services read that the "Vendor will provide 3 test trays per month (breakfast, lunch, dinner) for quality control. Dates and times will be determined by the Environment of Care Committee". Interview with the Registered Dietitian (RD) and the Food Service Director (FSD) confirmed test trays are done each month with varying results. The results are then reported to the Environment of Care Committee. There was no evidence that an analysis of the test tray results was done for quality control purposes.
-The Hospital's Contract for Food Services read that the "Vendor will conduct Patient Satisfaction Surveys / Staff Satisfaction Surveys twice a year. The outcome of these surveys will be submitted to the Center with appropriate Correction Plans". Interview with the Registered Dietitian (RD) and the Food Service Director (FSD) confirmed that Patient Satisfaction Surveys are conducted twice per year in September and March by the R.D. The results of the surveys are reported to the FSD, Environment of Care Committee and the Director of Nursing Services. There was no evidence that an analysis of the surveys was done and appropriate correction plans considered as needed.

See A-0084

Based on record review and interview, the Governing Body failed to determine, in accordance with State law, that Physician Assistants (PA), were an eligible category of practitioners for appointment to the medical staff, prior to hiring a PA.

Findings include:


1. During the entrance interview on 5/15/12 at approximately 9:30 A.M., the Chief Operating Officer (COO) said the Hospital had hired a Physician Assistant (PA) in January 2012, to replace the Nurse Practioner who had resigned. The COO said this was the first time the Hospital had hired a PA.

2. Review of the Medical Staff Bylaws at Article III indicated that categories of membership of Professional staff include active non-medical staff who are license a independent practitioners who are not physicians but who are licensed to provide patient/client care services independently in the State, who meet the qualification,standards and requirements of the Department of mental Health and these Bylaws and regularly have responsibility for patient care or the supervision of patient care in a specified recognized organizational role. Review of the Medical Staff Bylaws , Article V, Clinical Privileges Section 1, General Provisions , indicated that Appendix A provided a detailed description of the qualifications for each category of privileged membership and the specialized clincal privileges that may be requested for appointment to the Professional Staff Organization.

Appendix A listed the following privileged disciplines: Psychiatry which requires a current unrestricted medical license, General Medicine physicians which also requires a medical license, clinical nurse specialist which requires licensure from the Board of Registration in Nursing to practice in the expanded role, Nurse Practitioner which requires current licensure as a Registered Nurse in the the State and authorization/licensure by the Board of Registration in Nursing to serve in the Practitioner role, Psychology with a license to practice independently from the Board of Registration in Psychology and Pharmacist with a license to practice independently.

There is no privileged clinical category for Physician Assistants.

3. Review of Governing Body Minutes for one year, 5/2011 through 4/ 2012 indicated no action taken to amend the medical staff bylaws to include a clinical category for PA with defined privileges.

4. Review of PA #1 credentialing file indicated the Professional Staff Organization approved the PA for practice in the Hospital on 1/3/2012 and the Governing Body sent a letter to the PA on 2/13/12 stating privileges were granted effective on 1/3/12 through 1/3/14. Further review of the credentialing file indicated there was no supervisory agreement between the PA and a practicing physician at the Hospital as required by law, to monitor the PA 's practice and be available for consultation. Review of the delineation of privileges documentation, general medicine was checked and approved and written in by hand at the end of the document was "PA" was checked as requested and approved. However, in the Medical bylaws, there are no PA clinical privileges defined or approved.

Based on observation, staff interview and documentation review, the governing body failed to ensure that the contracted Food and Nutrition Vendor provided services in a safe and effective manner. The findings include:

1. Interview with the Food Service Director (FSD) and Dietitian (RD) on 5/15/2012 at 9:30 A.M. revealed that the Food and Nutrition Service within the Hospital was a contracted service. The Hospital's Contract for Food Service read that "the Vendor agrees to comply with the Center's policies, procedures and established protocols involving food and nutrition, quality management, infection control and safety".

2. The Hospital's Contract for Food Service further read that "Vendor employees shall be given an orientation upon hire and shall undergo a physical examination, including tuberculosis screening which conforms to the Center for Disease Control guidelines. The Vendor shall maintain documentation of these procedures". The Hospital's Infection Control Policy for employee health screening read that "Tuberculosis (TB) screening is required" upon hire and on "an annual basis thereafter".

Review of 7 Food Service Employee's Health Records revealed that TB screening was not done as required per Vendor Contract and Hospital Policy for 5 of 7 sampled employee health records (Employees #1, 3, 4, 5 and #6).

3. The Hospital's Contract for Food Service read that "the Vendor shall maintain the kitchen and cafeteria facility area in a presentable condition at all times. This includes counters, tables, serving areas, cabinets and storage areas."
The Hospital's Policy on Kitchen Sanitation read that "equipment, work surfaces, walls and floors are maintained in a sanitary condition by daily on-going procedures".

Review of the Hospital's monthly Infection Prevention Surveillance Reports for 1/26/12, 2/29/12 and 3/30/12 identified 12 areas of concern related to sanitation of equipment and utensils, dry storage and cafeteria service.

Observations of the Food Service Department on 5/15/12 and 5/16/12 revealed adequate sanitation was not maintained in the kitchen and the cafeteria.

4. The Hospital's Contract for Food Services read that the "Vendor will provide 3 test trays per month (breakfast, lunch, dinner) for quality control. Dates and times will be determined by the Environment of Care Committee".

Interview with the Registered Dietitian (RD) and the Food Service Director (FSD) confirmed test trays are done each month with varying results. The results are then reported to the Environment of Care Committee. There was no evidence that an analysis of the test tray results was done for quality control purposes.

5. The Hospital's Contract for Food Services read that the "Vendor will conduct Patient Satisfaction Surveys / Staff Satisfaction Surveys twice a year. The outcome of these surveys will be submitted to the Center with appropriate Correction Plans".

Interview with the Registered Dietitian (RD) and the Food Service Director (FSD) confirmed that Patient Satisfaction Surveys are conducted twice per year in September and March by the R.D. The results of the surveys are reported to the FSD, Environment of Care Committee and the Director of Nursing Services. There was no evidence that an analysis of the surveys was done and appropriate correction plans considered as needed.

Based on observation, record review and interview, the Hospital failed to assure that for one sampled patient (#5) and three nonsampled patients (NS (A), NS (H) and NS (I) ), the patient's assessed care needs were evaluated in order to anticipate potential emergency care scenarios and develop the policies, procedures, and staffing that would enable the Hospital to provide safe and adequate initial treatment of an emergency conditions that could arise and plan emergency services accordingly. Lack of such planning lead to an emergency condition of airway obstruction for NS (A) during a cardiac arrest, where the patient could not be ventilated for approximately 24 minutes, during resuscitation efforts, as observed and timed by surveyor, until EMS arrived and provided airway suctioning.

Findings include:

1. Observation of the three units, 4 East, 5 East and 8 East, on 5/15/12, at approximately 10:00 A.M., during the orientation tour, indicated that each area had portable oxygen with an Ambu bag, face masks, nasal cannulas, a rebreathing mask but no oral airways, an emergency drug box consisting of items such as an Epipen, injectable Benadryl, Glucagon and other oral medications. An AED (automatic external defibrillator) was observed on the 5 East unit. No suction machines were observed on any of the nursing units. During an interview with the 3-11 shift supervisor on 5/16/11 at approximately 2:00 P.M., the supervisor said the Hospital does not have any suction machines.

2. On 5/18/12 at 1:50 P.M., by the surveyor's watch, a Code Blue was paged to the 8 East unit. Surveyor went to the unit to observe the emergency response, arriving at 1:54 P.M. Patient NS (A) was observed on the floor between two beds. Staff were providing Cardio-pulmonary resuscitation (CPR) efforts. Registered Nurse (RN) #3, was attempting to ventilate the patients with an Ambu and face mask. RN #2 said "I can't ventilate the patient!" air could be heard leaking from the seal between the facemask and the patient's mouth and a high pitched sound from the patient's airway was heard indicative of an airway obstruction. Staff were observed to reposition the patient head with no improvement in the ability to ventilate the patient . There was no suction machine in the room to clear the patient's airway.

A nurse was observed to be providing chest compressions. At approximately 1:58 P.M., Physician #1 arrived on scene and entered the room, stood over NS (A), did not perform any exam, said "continue CPR" and left the room. The physician did not take over leader of the Code Blue per the Code Blue protocol.

NS (A) was observed to be turned on his/her side twice, staff stating the patient was vomiting clear liquid. No suctioning was done to help clear the airway and no improvement in the ability to ventilate was observed. Staff then repositioned the patient on his/her back and continued chest compressions and attempted to ventilate the patient. At one point, staff abandoned using the ambubag and went to trying mouth to mouth resuscitation with a barrier because of the inability to establish an open airway. At this time, the surveyor was observing from outside the room. The surveyor observed the soles of the patient's feet were turning a deep purple black and the legs were mottled. This is a sign of tissue hypoxia, a lack of oxygen to the tissues.

At approximately 2:07 P.M., the Emergency Medical Services (EMS) arrived and assumed care of the patient. The EMS immediately asked for suction and were told the staff did not have any. The EMS staff were then observed to send one of their members back out to the ambulance on the street level to retrieve portable suction, delaying opening of the patient's airway another 4-5 minutes. EMS was observed, after obtaining suctioning apparatus, to suction the patient and intubate the patient at approximately 2:15 P.M. Surveyor observed that within 5-10 minutes, the color in the patient's feet returned to a dusky pink.

After the patient had left via ambulance, two fire and rescue staff remained to collect equipment. When they began to exit the floor at 2:35 P.M., the surveyor walked out with them and inquired if they knew the reason staff were not able staff to ventilate the patient. Fire and rescue staff said that the patient's airway was impacted with food, probably from regurgitation during the initial CPR effort, and the patient needed suctioning to open the airway.

This patient had obstructed airway that needed suctioning to clear for approximately 24 minutes but suctioning equipment was not available in the Hospital's emergency equipment. .

3. In addition, the Hospital failed to accurately assess the needs of it's patient population and plan accordingly for patient's at risk for airway obstruction, aspiration and related emergencies.

The Hospital policy for Emergency Response, last reviewed and updated on 3/31/09, for medical emergencies, indicated that for a Code Blue (medical emergency of any kind) all available physicians will respond. The medication nurse from the 5th floor will respond with the emergency cart, medication box and AED (automatic external defibrillator). Campus police will also bring an AED. All available trained staff will also respond. The first physician to arrive on the scene will be the leader and direct other to specific tasks. On arrival, the physician will clearly identify him/herself as the leader, will lead the coordinated emergency effort, including assessing the patient.

The first nurse accompanying the emergency cart ( observation indicated no cart ,just oxygen, medication box and AED), will open the oxygen tank and medication box and remain ready to respond to physician orders. The second nurse acts as a recorder. Step "e" stated "although most patients can be stabilized with basic life support, the physician and nursing staff will be alert for conditions that can safely and quickly treated and for which definite treatment is life saving. (See Attachment A)."

Review of Attachment A of the Emergency Protocol list recommends medical interventions. It states that intravenous (IV) lines will not be placed, therefore, IV medications cannot be administered. Oral airways, if indicated, will be placed by the physician. Oxygen (up to 2 liters may be started by the nurse). The attachment lists emergency conditions with common interventions available to staff,stating it is not exhaustive or prescriptive.

The list include cardiac arrest with an intervention of AED: hypoglycemia with an intervention of oral glucose for a patient who can swallow or intramuscular Glucagon; asthma with an intervention of oxygen and Albuterol inhaler: angina with an intervention of Nitroglycerin; anaphylaxis/laryngospasm with an intervention of Epipen injection or Benadryl IM: shock with an interventions of Trendelenburg position (feet elevated) and Status epilepticus ( prolonged tonic-clonic seizure) with an intervention of airway management and oxygen.

The list failed to address choking, aspiration and airway obstruction with recommended interventions.

2. Review of Hospital's CODE BLUE ( Medical emergencies) Information form, reviewed and revised on 3/3/09, under part III interventions, lists "aid given" which includes rescue breathing, Ambu bag, oxygen, suction, CPR and AED.

3. Review of Medical Staff Meeting Minutes from 3/16/12, indicated medical staff had identified NS (H) as a choking risk with a swallowing disorder. On 4/6/12, after the patient had a radiology appointment, the Medical staff notes indicated the patient was an "aspiration risk." There were no other actions identified to ensure safety other than to continue 1:1 supervision with eating.

4. Patient #5 had choking episode while eating with 1:1 supervision on 7/22/11. Heimlich maneuver able to clear airway. Using the assessment done on 10/14/11, by Registered Dietitian (RD) indicated the patient remains high risk for choking, holds food in mouth and had poor dentition. Medical staff minutes indicated no further action taken to ensure safety and the plan was to continue 1:1 and supervision with eating.

5. Medical Staff Meeting Minutes also indicated NS (I) was also assessed as high risk for choking. The plan was to continue ground diet and supervision with eating.

6. There was no evidence that the Hospital reviewed it medical emergency policy and procedures, since 3/09 even when aware of high risk aspiration and choke risk patients in the hospital, to incorporate a more comprehensive planned emergency response to meet the needs of the patients.

Based on review of grievances, hospital policy and staff interview, the hospital failed to respond, in writing, to 9 of 9 complaints, within 10 days as indicated in their policy. Findings include:

The hospital's Complaint and Appeal Process indicated the following, "The complaint shall be investigated and a decision shall be given to the parties: by the person in charge within ten days of receipt of the complaint."

A review of 9 complaints that were filed between 1/4/12 and 5/3/12, revealed that all 9 were not responded to, in writing, in ten days. The following are examples of the 9 complaints:

1. On 1/4/12, the hospital received a complaint regarding patient to patient abuse. The hospital investigated the complaint and completed a written report dated 1/25/12. The patient was not sent a letter until 2/22/12, 49 after the complaint was filed.

2. On 2/1/12, the hospital received a complaint regarding: a) an inappropriate tone of voice used by staff; b) refusal to store food items in the refrigerator, and; c) denial of access to kitchen area by staff in retaliation. The hospital investigated the complaint and completed a written report dated 2/23/12. The patient was not sent a letter until 3/8/12, 37 days after the complaint was filed.

3. On 4/2/12, the hospital received a complaint of inappropriate sexual behavior between clients. The hospital investigated the complaint and completed a written report dated 4/26/12. On survey date of 5/17/12, the patient had not been sent a letter. This was 45 days after the complaint was filed.

4. On 4/4/12, the facility received a patient complaint of theft/loss of an item. The hospital investigated the complaint and completed a written report dated 5/8/12. On survey date of 5/17/12, the patient had not been sent a letter. This was 43 days after the complaint was filed.

5. On 4/19/12, the facility received a complaint of an illegal restraint with injury to the wrist. The hospital investigated the complaint and completed a written report dated 4/27/12. On survey date of 5/17/12, the patient had not been sent a letter. This was 28 days after the complaint was filed.

6 During interview on 5/17/11 at 10:30 a.m., the Quality Manager stated that the she had interpreted the policy to mean that the investigation must be completed in 10 days. She stated that the letter to the patient was sent, in writing, at a later date.

Based on record review and staff interview, the hospital failed to review and revise the care plan for 5 of 5 restrained patients (#5, #21, #22, #28 and #29) in a total sample of 30 patients, after the discontinuation of the restraint or seclusion intervention .

Findings include:

1. For Patient #28, the hospital failed to update the care plan following 5 applications of restraints.

Patient #28 had a diagnosis of bipolar disorder - manic episode. The patient had a treatment plan dated 5/9/12.

The patient was restrained for behavior that was a danger to self and others as follows: a) on 5/3/12 at 9:00 A.M., with a 4-point mechanical restraint and chemical restraint; b) on 5/3/12 at 10:30 A.M., with a 4-point mechanical restraint and chemical restraint; c) on 5/3/12 at 6:00 P.M. with locked door seclusion and chemical restraint; d) on 5/4/12 at 7:30 A.M. with 4-point restraint and chemical restraint and; e) on 5/4/12 at 3:40 P.M. with a 4-point restraint.

The treatment plan was not updated to include the use of restraints upon discontinuation of the restraint intervention.

2. For Patient #22, the hospital failed up update the care plan following 4 applications of restraints.

Patient #22 had a diagnosis of chronic paranoid schizophrenia. The patient had a treatment plan dated 5/14/12.

The patient was restrained for behavior that was a danger to self and others as follows: a) on 5/1/12 with a 4-point mechanical restraint and chemical restraint; b) on 5/3/12 at 5:45 P.M., with a physical hold; c) on 5/3 at 6:35 P.M., with locked door seclusion and a chemical restraint and; d) on 5/9/12 with a 4- point physical and a chemical restraint.

The treatment plan was not updated to include the use of restraints. upon discontinuation of the restraint intervention.

3. For Patient #21, the hospital failed to update the care plan following 2 applications of restraints.

Patient #21 had a diagnosis of psychosis. The patient had a treatment plan dated 5/15/12.

The patient was restrained with a 4-point mechanical restraint and chemical restraint on 4/27/12 and on 5/3/12, for behavior that was a danger to self and others.

The treatment plan was not updated to include the use of restraints.

4. For Patient #29, the hospital failed to update the care plan following 2 applications of restraints.

Patient #29 had a diagnosis of schizoaffective disorder. The patient had a treatment plan dated 5/9/12.

The patient was restrained for behavior that was a danger to self and others as follows: a) on 5/8/12 with a physical hold and locked door seclusion; b) on 5/9/12 with a 4-point restraint and chemical restraint.

The treatment plan was not updated to include restraints upon discontinuation of the restraint intervention.

During interview on 5/21/12 at 2:30 P.M., the Charge Nurse (RN#4) acknowledged that the treatment plans were not updated following the use of restraints.



09115


5. For Patient #5, the Hospital failed to update the care plan following multiple applications of restraints.

Patient #5 had diagnosis of Schizophrenia with psychosis, dementia and severe outbursts of agitation.

Record review indicated the patient was placed in a physical hold restraint for the purpose of receiving chemical restraints on 4/12/12 due to severe behaviors and being at risk of self injurious behavior. On 4/24/12, the patient was placed in close door seclusion at 2:00 P.M. and at 4:00 P.M. the patient was placed in 4 point restraint due to violent behavior and being at risk for self injury and injury to to others. On 4/25/12, the record indicated the patient was placed in a physical hold at 1:00 P.M. for the purpose of administering a chemical restraint for severe self injurious behavior. This behavior occurred during close door seclusion the patient was placed in for throwing food and attacking staff. On 5/3/12, at 8:00 A.M., the patient was again placed in close door seclusion for combative and loud agitated behavior, not to exceed two hours.

The treatment plan, reviewed on 5/14/12, did not have any interventions or goals for use of restraints and was not updated to include the use of chemical, physical restraints and seclusion upon discontinuation of the restraint interventions.

Based on record reviews, interviews and review of the rules and regulations governing medical staff, the governing body failed to formulate specific criteria for credentialing Physician Assistants responsible for providing care to patients.

Findings include:

1. During the entrance interview on 5/15/12 at approximately 9:30 A.M., the Chief Operating Officer (COO) said the Hospital had hired a Physician Assistant (PA) in January 2012, to replace the Nurse Practioner who had resigned. The COO said this was the first time the Hospital had hired a PA.

2. Review of the Medical Staff Bylaws at Article III indicated that categories of membership of Professional staff included active non-medical staff who are licensed as independent practitioners who are not physicians but who are licensed to provide patient/client care services independently in the State, who meet the qualification, standards and requirements of the Department of Mental Health and these Bylaws and who regularly have responsibility for patient care or the supervision of patient care in a specified recognized organizational role. Review of the Medical Staff Bylaws Article V, Clinical Privileges Section 1, General Provisions , indicated that Appendix A provided a detailed description of the qualifications for each category of privileged membership and the specialized clincal privileges that may be requested for appointment to the Professional Staff Organization.

Appendix A listed the following privileged disciplines: Psychiatry which requires a current unrestricted medical license, General Medicine physicians which also requires a medical license, clinical nurse specialist which requires licensure from the Board of registration in nursing to practice in the expanded role, Psychology with a license to practice independently from the Board of Registration in Psychology and Pharmacist with a license to practice independently.

There is no privilege clinical category for Physician Assistants in Appendix A.

Review of Governing Body Minutes for one year, 5/2011 through 4/ 2012 indicated no action taken to amend the medical staff bylaws to include a clinical category for PA.

Based on record review of medical staff bylaws, the hospital failed to ensure that a bylaw was included to assure that a history and physical is completed within 24 hours, as required.


Findings include:

1. Record review of the Medical staff bylaws on 5/22/12 at 2:00 P.M., revealed that the document did not include a provision that the hospital complete an initial history and physical exam within 24 hours of admission as required by federal regulation.

See A-0458.

Based on record review and staff interview, the hospital failed to ensure nursing staff developed, reviewed, revised and/or implemented nursing care plans for 4 sampled patients ( #2, #5, #7 and #27) in a total sample of 30 patients. Findings include:

1. For Patient #27, the hospital failed to a) develop a care plan for falls and b)to correctly implement a care plan for a facial treatment.

a) Patient #27 had diagnoses of paranoid schizophrenia, anxiety, personality disorder, seizures and seborrhea eczema. The patient was admitted on 4/25/12.

The patient had an admission fall assessment that indicated a risk for falls due to psychiatric medications and a history of falls. The Fall Risk Assessment scored the patient as a 14. Any score above 10 indicated a high risk for falls. The treatment plan of 5/3/12 did not include falls.

During interview on 5/16/12 at 11:30 A.M., the Charge Nurse (RN#4) stated that they had not care planned the problem because Occupational Therapy (OT) had assessed the resident on admission and had not indicated a problem with gait. A review of the OT assessment dated 4/27/12, revealed no indication of problems with physical functioning however it did mention that the patient was at risk for seizures. A risk for seizures would create a risk for falls. There was no nursing care plan for seizures and safety precautions.

b) The patient had a physician's order dated 4/25/12, for hydrocortisone 1% cream , 1 application topically every day to facial eczema for seborrhea eczema.

A review of the Medication Administration Record for May 2012, indicated that the facial treatment was to be given at 8:00 A.M. and 8:00 P.M. It had been given twice a day on the following dates: 5/1, 5/2, 5/3, 5/8, 5/9, 5/10, 5/14 and 5/15. Other dates in May it was recorded as given only once a day.

During interview on 5/16/12 at 11:40 A.M., the Charge Nurse (RN#4) stated that the facial cream should have been applied once a day as ordered by the physician.



09115

2. For Patient #5, the Hospital failed to develop a care plan based on the areas identified in the nursing assessment of 10/14/12 and failed to implement the care plan for fall and failed to implement physician orders to assess skin twice a day, document date and time of all bowel movements and monitor food fluid intake.

Patient #5, admitted 10/09, had diagnosis of dementia, schizophrenia, severe agitation, and psychosis.

A nursing reassessment was conducted on 10/14/12 which indicated the patient was often seen with bruises, was incontinent of bowel and bladder, required extensive assistance with activities of daily living including feeding, with high risk for choking due to pocketing of food and poor dentition and a recent choking episode, had constipation, reported pain in the arm and headaches, and was high risk for falls.

Review of the treatment plan for hygiene, reviewed on 3/18/12, had as nursing interventions to meet with the patient once per shift or as needed, to assist with daily hygiene need and also to educate the patient and promote independence.

During an interview on 5/16/12 at approximately 10:00 A.M., Mental Health Worker (MHW) #1 said the patient has required almost total care due to behavior for a long time and due to incontinence staff shower the patient up to three times a day. MHW #1 said the patient has no ability to learn any self care. MHW #1 said the patient urinates and defecates inappropriately, does not wear a brief but staff try to toilet him every 20 minutes without success.

Review of the nursing care plan indicated no interventions planned for managing constipation or pain. The choking plan stated staff would monitor patient during eating and observe for choking and ensure patient received a dental soft diet.

The fall care plan, dated 4/11/11, stated the staff would ensure that the patient is wearing safe footwear in order to be able to ambulate safely in the milieu without falling. Observation on 5/15/12 at 10:00 A.M., 5/16/12 between 8:30 A.M. and 12:00 P.M. and 5/17/12 between 9:00 A.M. and 1:00 P.M., the patient was observed walking in the unit and in seclusion room without shoes or footwear on.

On 4/26/12, the physician ordered skin checks by nursing twice a day and to document date and time of all bowel movements and monitor food and fluid intake. Review of the physician progress notes indicated the patient was having a slow weight loss and was being assessed to rule out colon cancer.

Review of progress notes indicated that on 5/3/12, the physician examined the patient at the request of staff due to a mass on the patient's right buttock. The physician determined it was an inflammatory mass most likely due to intramuscular (IM) injections. Review of nursing progress notes and treatment sheets after 5/3/12 indicated no assessment of the area during the twice a day skin checks that were signed off as done.

On 5/16/12, at 10:00 A.M., during an interview, RN #1 said she had checked the patient's skin that morning and found no changes from the previous day. When asked about the right buttock lump, RN #1 said she did not know about the lump and admitted she did not observed the patient's buttock's and private areas today and yesterday. RN #1 later reported s/he checked the area and found no lump.

Record review from 4/26/12 through 5/16/12 indicated no documentation of date and time of all bowel movements as ordered. MHW did record percent of meals eaten but not fluids taken. During an interview on 5/17/12 at approximately 12:00 P.M., the evening supervisor said all the information ordered was not documented.

3. For Patient #2, admitted 11/11, the nursing care plan was not revised to reflect the patient new diagnosis and treatment for hypothyroidism on 2/8/12.

Record review indicated the patient had an elevated TSH (thyroid stimulating hormone) level on 2/8/12 of 5.37, and the Physician Assistant began replacement hormone therapy with Synthroid 50 micrograms daily. A diagnosis of hypothyroidism was documented in the clinical record.

Review of the current care plan indicated no interventions for nursing such as monitoring the effects of the medications, monitoring for signs and symptoms of hypothyroidism or providing patient education related to the new diagnosis and medication.

4. For Patient #7, the nursing care plan lacked interventions to address assessed nursing and medical problems.

Patient #7, admitted 2/12, had diagnosis of schizophrenia, asthma, hypertension, diabetes, and paranoia.

Record review indicated that on 4/1/12 the patient started on an oral agent for hyperglycemia, Metformin 500 milligrams (mgs) twice a day. The nursing care plan was not reviewed and revised with interventions to monitor the patient for signs and symptoms of hypoglycemia, a potential side effect of Metformin.

Record review indicated the patient was prescribed multiple medications for the management of hypertension to include Hydrochlorothiazide 25 mg daily, Lisinopril 20 mg daily and Propranolol 20 mg twice a day prescribed for akathisias but has an effect on blood pressure. review of the nursing care plan indicated no interventions or goals for blood pressure management.

On 5/14/12, the patient developed a dental abscess with facial swelling secondary to a broken tooth requiring oral antibiotic treatment. Review of the treatment plan which was updated on 5/14/12, indicated no nursing interventions for the care, monitoring and evaluation of pain related to the dental abscess.

The only nursing intervention under health and wellness for nursing in the treatment plan stated that nursing will monitor health status and report any changes to primary medical team; will also implement any interventions as needed.

Nursing failed to identify interventions needed to address physical changes or problems when identified.

Based on record review and interview, the Hospital failed to document in the medical record of one patient (#1), in a total active sample of 30, information to support decisions to delay activating protocols for away without authorization (AWA) and for determining the patient's potential discharge status in response to treatment before the AWA occurred.

Findings include:

1. Record review for Patient #1 indicated the patient was under a Section 7 , 8 and 8B court commitment through 5/29/12 and had individual privileges to leave the unit for 30 minutes twice a day, effective as of 4/23/12.

Review of the Patient Sign IN/Out sheets for 5/6/12 indicated the patient signed off the unit at 10:00 A.M. and was due back at 10:30 A.M. The patient did not sign back in. Review of the Mental Health Worker's every half hour check sheet for 5/6/12, for Patient #1, had the patient out on privileges from 10:00 A.M., until 6:30 P.M. when the patient was coded as being AWA.

The Notification to Campus Police for AWA, dated 5/6/12, at 19:55 (5:55 P.M.) indicated the patient went absent without authorization on 5/6/12 at 10:45 A.M.

Record review indicated the Medical Director wrote a progress note at 21:37 (7:30 P.M.) on 5/6/12, which stated the patient's above court ordered status, stated the patient remains delusional but in good behavioral control at the time of the elopement. The plan stated "AWA status, notified executive on call and best alert in place."

Review of the physician orders indicated the AWA status was written at 10:00 A.M. on 5/6/12 by the Medical Director.

Review of the progress notes indicated that on 5/9/12 the Social worker was notified by a local shelter that the patient had been their the previous night. The SW documented that the Director of SW and the attending Psychiatrist were consulted who felt that the patient was "not committable at this time." The shelter was asked if the patient returned to let him/her know they could return to the hospital at any time.

On 5/9/12, the patient returned to the hospital to visit and was told h/she was legally committed to the unit until 5/29/12 and she walked in on his/her own.

During an interview, on 5/18/12 at 1:30 P.M., the Director of Social Work said he and the psychiatrist decided not to Section 12 the patient back to the hospital because the patient was in good behavioral control and they were not going to renew the Section 7 and 8 after 5/29/12. This was not reflected in any documentation prior to the patient's AWA.

During an interview on 5/21/12 at 11:00 A.M., Registered Nurse (RN) #5 said the AWA for Patient #1 was not initiated at 10:30 A.M. because the physician wanted to give the patient time to return on his/her own. RN #5 stated the medical record documentation does not reflect any of this decision making and the physician failed to write an order extending the privilege time.

3. Patient # 12 was admitted on 5/9/12 with diagnosis including opiate dependency and rule out malingering.

The patient was committed to the hospital on a 15 b, which is a court ordered inpatient evaluation of a pre-trial criminal defendant for determination of competency to stand trial and /or criminal responsibility.

Record review on 5/16/12, at 10:30 A.M., revealed that the admission history and physical had not yet been completed .A progress note dated 5/10/12 revealed that the patient initially refused the history and physical exam. There was no further documentation that an attempt had been made to complete this initial physical examination.

The charge nurse said on 5/16/12 , at 1:30 P.M., that the initial exam had not yet been completed.


4. Patient # 9 was admitted to the hospital on 5/2/12 with diagnosis including rule out dementia, IV drug abuse, alcohol abuse/ dependence and hepatitis C.

Record review revealed on 5/21/12 at 10:45 A.M., that the initial physical exam was refused on an unspecified date. The exam was completed on 5/7/12, a five day period after admission. There was no further documentation that an attempt had been made to complete this initial physical examination until 5/7/12.









09115


Based on record review and staff interviews, the Hospital failed to ensure that 3 of 30 sampled patients ( #3, #10, #12 ) and one nonsampled patient (NS A), had medical history and physical examination (H&P) documented in the patient record within 24 hours after admission.

Finding include:

1. Patient #10, admitted 4/30/12, for a 15 day evaluation, did not have a H and P documented in the medical record until 5/7/12. According to the physician assistant progress of 5/7/12, "refused could not coordinate with interpreter." There was no further documentation the PA attempted to complete the H and P over the next several days until 5/7/12.

2. Patient #3, admitted 9/17/11, did not have a H and P documented in the medical record until 9/22/11. No reason was found for the late submission.

3. Patient NS (A), admitted on 5/14/12, for a 15 day evaluation, did not have an admission H and P documented in the medical record as of 5/18/12. The patient had a cardiac arrest on 5/18/12 and died at the hospital.

Record review indicated the mental health worker documented vitals signs on 5/14/12 at 8:30 P.M. The blood pressure was documented as 175/ 116 with normal readings being (90-130)/(60-80) and documented the pulse oximetry (measure of saturation of hemoglobin with oxygen) as 64%( acutely abnormal) with the normal being 95-100%.

The admission Psychiatric Assessment, dated 5/14/12, timed 8:30 P.M., noted a history of hypertension, question of renal failure and benign prostatic hypertrophy. The abnormal vital signs were not addressed.

On 5/15/12, at approximately 5:00 P.M., the physician assistant, wrote a progress note indicating the patient had refused the H and P exam and the PA planned to attempt again when "better able to participate in care."

There was no further documentation the PA attempted to complete the H and P over the next several days and no evidence the abnormal vital signs were addressed.

Based on record review and interview, the Hospital failed to ensure that all echocardiograms (ECG) were read promptly and those results were in the patient medical records for 2 of 30 patients ( #7, #10), so that health care staff involved in the patient's care can access/retrieve this information in order to monitor the patient's condition and provide appropriate care.

Findings include:

1. Patient #7, admitted in 2/2011, has diagnosis of hypertension, diabetes , asthma and schizophrenia.

Interview on 5/15/12 at the opening conference with the Chief Operating Officer, Director of Nursing and Quality Manager, indicated the Hospital had a consulting Medical physician who was responsible for reading all ECG's.

Record review indicated the patient had a routine ECG done on 7/25/11. The EKG machine interpretation indicated the patient was in sinus rhythm had left ventricular hypertrophy and had extensive ST-T wave changes which may be due to hypertrophy or ischemia (lack of oxygen reaching the heart tissue). It was labeled an abnormal ECG.

The 7/25/11 ECG was not read by the consulting Medical physician until 11/15/11 and whose only comment on the ECG was "baseline artifact."Another ECG was done on 11/3/11, which the consulting physician read on 11/15/11 and noted no major change from 7/2511, nonspecific T wave changes, commenting that in absence of clinical evidence of ischemic heart disease no further investigation is recommended.

On 3/28/12, the physician assistant annotated the report with physician "recommends echocardiogram if patient is symptomatic."

2. Patient #10 was admitted for a 15 day evaluation on 4/30/12. On 5/2/12, a routine ECG was ordered.

Nursing notes indicate the ECG was done on 5/4/12. Record review on 5/21/12 indicated the patient was discharged on 5/15/12. There was no ECG report in the record and no report of its results at the time of the patient's discharge.

Based on documentation and staff interview, the facility failed to provide planned written menus to meet the special needs of patients on mechanically altered diets including 3 sampled patients (#5, #15 and #27) on ground diets. The findings include:

1. On 5/16/12 the surveyor reviewed the "diet change sheets" which listed the prescribed diet order for each patient as well as each patient's food preferences. The diet sheets indicated three sampled patients (#5, #15 and #27) who required ground diets due to histories of dysphagia, choking episodes and/or dental problems.

2. Review of the 5 Week Menu Cycle revealed no written planned menus for texture modified diets.

3. Interview with the Dietitian on 5/16/12 at 10:00 A.M. confirmed the Hospital does not have written planned menus for texture modified diets including the ground diet but stated that Food Service Staff are trained on texture modifications so the patients receive the appropriate diet.

4. Observation of lunch on 5/21/12 revealed the main entree was a corned beef sandwich and the alternate was a turkey sandwich which are not appropriate textures for patients on ground diets. For 1 (#15) of the 3 sampled resident's meals observed, the Food Service Staff served a hot meal with ground chicken.

5. For these three patients who are at nutritional risk due to dysphagia, dental problems and require texture modifications, the facility did not have a planned written menu for mechanical altered diets for kitchen staff to follow to ensure these patients received a balanced and varied diet daily to meet their special needs.

Based on observation and interview, the Hospital failed to maintain the gym floor in a manner to ensure the safety and well being of 6 sampled patients (#2, #7 , #8, #26, #29 and #30) and 6 nonsampled patients (NS B, NS C, NS D, NS E , NS F and NS G) who have privileges to use gym. Findings include:

Observation of the gym on 5/21/12 at 9:30 A.M. by two surveyors indicated that on one half of the gym floor large patches of the floor surface were gouged out exposing the rough cement undersurface. This posed a fall and injury risk to anyone playing on the floor.

The areas of missing floor surface were as follows: two large areas approximately 3 feet by 2.5 feet and three smaller areas approximately 1 foot by 8 inches. There were multiple small areas. There was evidence that some small areas, less than 4 inches round had been previous patched.

During an interview with a housekeeper responsible for cleaning the gym floor, stated the gym floor had been damaged this way for years.

During an interview on 5/21/12 at 10:45 P.M., RN #3 said there were 6 patients from the 4 East unit who had gym privileges and per interview on 5/21/12 at 11:00 A.M., 8 East Unit Manager said there were 6 patients who had gym privileges.

Based on observation and documentation review, the Hospital failed to maintain the Food Service Department's equipment and supplies to ensure acceptable levels of safety and quality. Findings include:

1. During the tour of the Food Service Department on 5/15/12 at 9:30 A.M., the following was observed: the walls and floors edges throughout the main kitchen were dirty. In the dishmachine room, the caulking at the wall corners was loose and discolored; the wall tiles behind the dirty end of the dishmachine had a black discoloration; one overhead light was burnt out.

2. The following equipment was dirty with grease, dust, food debris and/or food stains: the exterior doors, handles and interiors of the refrigerators, the transport carts, convection ovens' bottom shelf and doors, condiment containers, fryolators, storage bins for serving utensils, rice storage bin, can opener base, ice scoop holder, utensil drawer, bottom shelf of the warmer unit and the fan covers in the walk-in freezer.

3. In the pantry, both light covers were dirty and one light cover was loose. The sugar storage bin was not labeled and a styrofoam bowl used as a scoop was stored in with the sugar. Floor edges were dirty. In the beverage room, two insulated beverage containers were stored on the floor.

4. In the cafeteria, the following was in need of cleaning: floor, floor edges, floor drains and the exterior door, handle and interior of the reach-in warmer. On 5/16/12 at 11:00 A.M., a rolled up floor mat was stored in front of the hand wash sink blocking access to the sink.

5. Review of the Hospital's monthly Infection Prevention Surveillance Reports for 1/26/12, 2/29/12 and 3/30/12 identified 12 areas of concern related to the sanitation of equipment and utensils, dry storage and cafeteria service.

The Hospital failed to maintain their kitchen equipment, service areas and storage areas to ensure an acceptable level of safety and quality.

Based on record review and interview, the Hospital failed to provide one patient (#3), in a total active sample of 30, (a) a referral as ordered for physical therapy, (b) an evaluation and treatment plan by Occupational therapy and (c) and failed to provide services as ordered by the physician. Findings include:

1. Patient #3, admitted in 9/2010, with a diagnosis of schizophrenia. Record review indicated the patient had been receiving Tylenol as needed since admission for complaints for left shoulder and arm pain.

Review of physician progress notes dated 1/26/12, indicated the patient complained of worsening left shoulder pain and a follow-up with orthopedics would be done as well as an x-ray. The physician assistant (PA) wrote that Tylenol every night at bedtime would benefit the patient.

Record review indicated the patient saw the Orthopedic physician on 3/14/12 who noted the patient had decreased range of motion (ROM) in the left shoulder with pain, left hand pain and did not tolerate nonsteroidal anti- inflammatory drugs. The physician 's diagnosis was rotator cuff tendinitis/bursitis and he prescribed a sponge for left hand exercises 10 repetitions twice a day and Voltaren 50 milligrams twice a day. The physician also prescribed physical therapy twice week for 6 weeks to include external and internal stretching and strengthening, scapular stabilizer exercises, Active/active assisted ROM, grip strength and strength exercises.

On 3/21/12, record review indicated the PA signed the orders for PT and wrote orders for the Voltaren. The PA also wrote a progress note stating that s/he ordered PT.

Record review indicated that as of 3/29/12, no PT services had been initiated. On 3/29/12 at 9:30 A.M., the physician wrote an order for "referral to Occupational therapy (OT) for upper body exercises."

Further record review indicated there was no OT functional evaluation done as of 5/18/12 to establish a treatment plan with type, frequency and duration of therapy to include diagnosis and anticipated goals, related to the left shoulder tendinits diagnosis.

Review of the OT progress notes, dated 3/23/12, indicated the OT was aware of the patient's left shoulder problem and recommended treatment orders. The OT stated in the note that " will meet with patient to review ROM and shoulder exercises next week."

On 4/1/12 and 4/13/12, the OT indicated the patient participated in 1:1 with OT for treatment of the left shoulder. There was no further documentation of therapy for the left shoulder.

During an interview on 5/17/12, at 12:30 P.M., the OT who provided care to the patient said a function assessment was not completed upon receiving the referral and OT did not see the patient as often as they would have liked to treat the shoulder but the patient reported feeling better. The OT said there was an order from the PA for OT to provide services. (Order was only for referral).

During an interview on 5/22/12 at approximately 10:00 A.M. , Unit Manager #1 said that the consult with Physical therapy was not discontinued and should have been initiated. UM #1 also said there were no treatment orders for the OT other than the referral.

Based on record review and interview, the facility failed to develop Master Treatment plans (MTPs) for 6 of 9 active sample patients (A3, A19, B6, B10, B21, and C14) that had short term goals stated as patient outcome behaviors. Instead, the goals were stated as staff goals or needs. This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions, based on changes in the patient behaviors.

Findings include:

A. Record Review (MTP dates in parenthesis)

1. Hospital policy number R-10, titled "Multidisciplinary Treatment/Recovery Plan", updated 3/6/12, stated: "The Master Treatment/recovery plan consists of patient specific behavioral goals."

2. Active Sample Patient A3
The MTP (4/18/12) staff goal/needs were: "Patient will complete all admission assessments", "Patient will comply and complete all routine labs and assessments and blood work."

3. Active Sample Patient A19
The MTP (5/2/12) staff goal/need was: "Patient will complete psychological testing", "Patient will complete substance abuse assessment."

4. Active Sample Patient B6
The MTP (5/16/12) staff goal/needs were: "Pt [patient] will participate in psychiatric assessments and recommended treatment". "Pt will complete substance abuse assessment". "Pt will participate in initial medical assessment and follow-up lab work."

5. Active Sample Patient B10
The MTP (5/10/12) staff goal/needs were: "Patient will agree to accept all psychiatric medications as prescribed", "Patient will comply with substance abuse assessment", "Patient will allow admission blood draws, screening processes to be performed as requested."

6. Active Sample Patient B21
The MTP (5/15/12) staff goal/needs were: "Pt will participate in psychiatric assessments and recommended treatment", "Pt will complete substance abuse assessment", "Pt will participate in initial medical assessment and follow-up lab work."

7. Active Sample Patient C14
The MTP (5/9/12) staff goal/need was: "Patient will maintain current health status through cooperation with routine assessment and treatment of her identified health issues by doing weekly vital signs, weight over the next 7 days."

B. Interviews

1. In an interview on 5/17/12 at 9:21a.m., the staff goals on the Master Treatment plans were discussed with RN1. RN1 stated that the goals were consistent with the problems of forensic patients and therefore were suitable to address in all the plans.

2. In an interview on 5/8/12 around 10a.m., the staff short term goals on the Master Treatment plans were discussed with the Medical Director. The Director did not dispute the findings. "There is always room for improvement."

Based on record review and interview, the facility failed to develop Master Treatment plans (MTPs) that addressed the individual needs of 8 of 9 active sample patients (A3, A19, B6, B10, B21, C12, C13, and C14). Instead, many interventions were routine, generic discipline functions that would be provided for any patient regardless of specific goals and needs. This deficiency results in treatment plans that do not reflect a comprehensive, integrated individualized approach to patient care.

Findings include:

A, Record Review (MTP dates in parenthesis)

1. Hospital policy number R-10, titled "Multidisciplinary Treatment/Recovery Plan", updated 3/6/12, stated: The Master Treatment/Recovery plan consists of "All treatment interventions and modalities provided to the patient" and "Will relate to identified problems and goals for the patients."

2. Active Sample Patient A3 (MTP 4/18/12)
Problem - "Legal charges in the context of mental illness"
Intervention - "Psychiatry - MD will meet with patient for 15 minutes twice a week to assess mental status, prescribed (sic) medication as needed, monitor for efficacy and effects."
Problem - "Health and wellness"
Intervention - "Medicine- will meet with patient to assess medical needs, prescribe medication as needed, and make consults as needed."
"Nursing- will meet with patient once a shift for 10 minutes to encourage compliance with routine assessments."
"Nursing- will encourage compliance with routine ADLs [activities of daily living] and provide education and resource as needed."

3. Active Sample Patient A19 (MTP 5/2/12)
Problem - "Legal charges in the context of possible mental illness"
Intervention - "Psychiatry - will meet with the patient once a week for 15 minutes to assess mental status and prescribe medications as needed and provide psychoeducation on treatment adherence."
Problem - "Substance abuse."
Intervention - "Addiction specialist - will meet with patient to complete substance abuse assessment and provide group schedule."

4. Active Sample Patient B6 (MTP 5/16/12)
Problem - "Legal/safety"
Interventions - "Psychiatry - MD will meet with pt [patient] twice weekly for 10 minutes to assess mental status, monitor behavior, prescribe medication and monitor efficacy/side effects."
"Nursing - will meet with pt daily for 5 minutes to assess mental status, monitor for side effects. Monitor for safety and provide support/options, such as Sensory room [a type of relaxation room], to assist in maintaining safe behaviors."
Problem - "Alcohol/marijuana abuse"
Intervention - "Addiction specialist - will meet with pt for 45 minutes to complete comprehensive substance abuse assessment and report back to team."
Problem - "Health/wellness"
Intervention - "Medicine - will provide initial medical assessment including physical exam and review medical conditions/issues as needed."

5. Active Sample Patient B10 (MTP 5/10/12)
Problem - "Stabilize symptoms of mental illness/maintain safety"
Intervention - "Psychiatry - will meet with the patient once per week to assess mental status, prescribe medication if necessary, monitor for side effects and efficacy and educate the patient about mental illness."
Problem - "Substance abuse"
Intervention - "LADC [licensed Addiction Counselor] will meet with patient for 45 minutes to complete substance abuse assessment and make recommendations for treatment."
Problem - "Health/wellness"
Intervention - "Medical team - will assess lab work and results of physical exam and provide any indicated physical health treatment."

6. Active Sample Patient B21 (MTP 5/15/12)
Problem - "Legal"
Interventions - "Psychiatry - will meet with pt twice weekly for 10 minutes to assess mental status, monitor behavior, prescribe medication and monitor efficacy/side effects." "Nursing - will meet with pt daily for 5 minutes to assess mental status, monitor behavior, assess mental status, monitor behavior, administer medication as prescribed and monitor side effects."
Problem - "Alcohol/marijuana abuse"
Intervention - "Addiction specialist - will meet with pt for 45 minutes to complete comprehensive substance abuse assessment and report back to team."
Problem - "Heath/wellness"
Intervention - "Medicine - will provide initial medical assessment including physical exam and review medical conditions/issues as needed."

7. Active Sample Patient C12 (MTP 5/16/12)
Problem - "Hypo-mania"
Interventions - "Psychiatry - will meet with patient three times per week for 10 - 15 minutes to assess mental status, monitor for the efficacy and side effects of medication and modify medication regime as clinically indicated."
"Nursing - will administer medication as ordered, monitor for efficacy and side effects and offer PRN (as needed) medications as indicated for increased agitation."
Problem - "Health/wellness"
Intervention - "Medicine - will review patient's H&P [History and Physical], labs and vital signs, and make recommendations for further medical interventions."

8. Active Sample Patient C13 (MTP 5/11/12)
Problem - "Psychosis"
Intervention - "Social work - will meet with patient daily over the next week for 5-10 minutes to gather history, assess current mental status."
"Psychiatry - will meet with patient three times over the next week for 10 minutes to assess mental status, start anti-psychotic medications and assess for efficacy and side effects."
"Nursing - will meet with patient as needed over the next week to complete nursing assessments."
Problem - "Health/wellness"
Interventions - "Nursing - will prompt [sic] patient for vital signs and getting lab work done and recommended medical procedure."
"Nursing - will prompt patient to shower daily, change clothes, and perform ADLs."

9. Active Sample Patient C14 (MTP 5/9/12)
Problem - "Behavioral disruption/community reintegration"
Intervention - "Nursing - will administer medication as prescribed, offer PRNs when clinically indicated, and monitor for efficacy and side effects."
"Psychiatry - will meet with the patient twice per week for 15" [minutes] to monitor medications for efficacy and side effects and modify medication regime as clinically indicated."
Problem - "Health/wellness"
Intervention - "Medicine - will review patient's labs, physical, and vital signs and make appropriate medical recommendations."

B. Interviews

1. In an interview on 5/17/12 at 8:45a.m., the generic nursing interventions were discussed with the Nursing Director. The Nursing Director agreed with the findings.

2. In an interview on 5/18/12 around 10a.m., the generic physician interventions on the Master Treatment plans were discussed with the Medical Director. The Director agreed that the interventions were general, but "there is always room for improvement."

Based on record review and interview, the Medical Director failed to ensure quality and appropriateness of services provided by the medical staff. Specifically, the Medical Director failed to ensure that:

1. Short term goals were described in measurable outcome behavioral terms for 6 of 9 active sample patients (A3, A19, B6, B10, B21, and C14). Instead, the goals were stated as staff goals or needs. This deficient practice hampers the ability of the treatment team to provide goal directed treatment and to determine the effectiveness of interventions, based on changes in the patient behaviors. (Refer to B121.)

2. Interventions on the Master Treatment plans addressed the individual needs of 8 of 9 active sample patients (A3, A19, B6, B10, B21, C12, C13, and C14). Instead, many interventions were routine, generic discipline functions that would be provided to any patient regardless of specific goals and needs. This deficiency results in treatment plans that do not reflect a comprehensive, integrated individualized approach to patient care. (Refer to B122.)

Based on record review and interview, the Nursing Director failed to ensure that nursing staff developed interventions on the Master Treatment plans that addressed the individual needs of 6 of 9 active sample patients (A3, B6, B21, C12, C13 and C14).


Findings include:

A, Record Review (MTP dates in parenthesis)

1. Hospital policy number R-10, titled "Multidisciplinary Treatment/Recovery Plan", updated 3/6/12 stated: The Master Treatment/Recovery plan consists of " All treatment interventions and modalities provided to the patient" and "Will relate to identified problems and goals for the patients."

2. Active Sample Patient A3 (MTP 4/18/12)
Problem - "Health and wellness"
Intervention - "Nursing- will meet with patient once a shift for 10 minutes to encourage compliance with routine assessments."
"Nursing- will encourage compliance with routine ADLs [activities of daily living] and provide education and resource [sic] as needed."

3. Active Sample Patient B6 (MTP 5/16/12)
Problem - "Legal/safety"
Interventions - "Nursing - will meet with pt [patient] daily for 5 minutes to assess mental status, monitor for side effects. Monitor for safety and provide support/options such as sensory room [a type of relaxation room] to assist in maintaining safe behaviors."

4. Active Sample Patient B21 (MTP 5/15/12)
Problem - "Legal"
Interventions - "Nursing - will meet with pt daily for 5 minutes to assess mental status, monitor behavior, administer medication as prescribed and monitor side effects."

5. Active Sample Patient C12 (MTP 5/16/12)
Problem - "Hypo-mania"
Interventions "Nursing - will administer medication as ordered, monitor for efficacy and side effects and offer PRN (as needed) medications as indicated for increased agitation."

6. Active Sample Patient C13 (MTP 5/11/12)
Problem - "Psychosis"
"Nursing - will meet with patient as needed over the next week to complete nursing assessments."
Problem - "Health/wellness"
Interventions - "Nursing - will prompt [sic] patient for vital signs and getting lab work done and other recommended medical procedures."
"Nursing - will prompt patient to shower daily, change clothes, and perform ADLs."

7. Active Sample Patient C14 (MTP 5/9/12)
Problem - "Behavioral disruption/community reintegration"
Intervention - "Nursing - will administer medication as prescribed, offer PRNs when clinically indicated, and monitor for efficacy, and side effects."


B Interview

In an interview on 5/17/12 at 8:45a.m., the generic nursing interventions were discussed with the Nursing Director. The Nursing Director agreed with the findings.