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23515 HIGHWAY 190

MANDEVILLE, LA 70448

INDIVIDUAL COMPREHENSIVE TREATMENT PLAN

Tag No.: B0118

Based on record review and staff interview, the hospital failed to ensure the nursing staff developed and kept current an individualized comprehensive treatment plan as evidenced by:
1) failing to include Axis III diagnoses for 4 (F1, F2, F3, F5) of 5 (F1-F5) sampled patients;
2) failing to include interventions to address all identified patient problems for 1 (F5) of 5 (F1-F5) sampled patients, and;
3) failing to update the treatment plan to reflect changes in the patient's condition and the use of restraint/seclusion for 1 (F4) of 5 (F1-F5) sampled patients.

Findings:

Review of the Hospital Policy and Procedure titled Treatment Planning, Policy # TX.1-0200, effective 7/1/13, revised 06/16/14, revealed in part:
Purpose: To assure that the patient/family/guardian, and all members of the treatment team have the opportunity to provide input into treatment planning and to assure development of a comprehensive and complete plan of care that serves as a guide for providing individualized treatment....
B. Axis III/Intercurrent Medical Problems: All Units:
Axis III diagnoses (General Medical Conditions) must be addressed in the treatment plan:
3. If it is an active problem (receiving current treatment) then a plan of care with objectives and interventions is required.
An "active" medical problem is indicated when:
a. the condition significantly affects the psychosocial or psychological functioning of the patient,
b. the condition requires multiple interventions,
c. the condition requires ongoing treatment to maintain control and if uncontrolled can adversely affect the patient's health....
E. Interventions: 2. Interventions must be individualized to patient needs and relate to the treatment objectives.
F. Updating the Treatment Plan:
1. The treatment plan/ISP must be updated to reflect change in patient condition; the following requires modification of the treatment plan prior to scheduled update:
a. Newly diagnosed medical condition with ongoing treatment.
b. Use of F/R, A/R, L/S (Full Restraints, Ambulatory Restraints, Locked Seclusion)
d. Precautions added for violence, suicide, elopement....

1) Failing to include Axis III diagnoses:

Patient #F1
Patient #F1 was a 35-year-old female admitted to the hospital on 12/25/14. Axis I diagnoses included Depression and Suicidal Ideations. Axis III (Medical) Diagnoses included Hypertension (High Blood Pressure), Hypothyroidism, Seizure Disorder and Gastroesophageal Reflux Disease (GERD).
Review of the Initial Care Orders dated 12/25/14 revealed the Axis III Diagnoses of Seizures and Hypertension.
Review of the History and Physical dated 10/26/14 revealed the Axis III Diagnoses of Seizures, Hypertension, Hypothyroidism, and Gastroesophageal Reflux Disease (GERD).
Review of the Psychiatric Evaluation dated 12/26/14 revealed the Axis III Diagnoses of Seizures, Hypertension, Hypothyroidism, and Gastroesophageal Reflux Disease (GERD).
Review of the Initial RN (Registered Nurse) Assessment dated 12/25/14 revealed the Axis III diagnoses of Hypertension and Seizures.
Review of the Medication Reconciliation Sheet (medications patient was taking at home prior to admission to the hospital) revealed Patient #F1 was taking Amlodipine (anti-hypertensive), 5 mg (milligram) once daily; Dilantin (anti-seizure) 60 mg twice per day; Levothyroxine (hypothyroidism) 75 mcg (micrograms); Omeprazole (GERD/anti-reflux) 20 mg once daily.
Review of the physician medication orders revealed Patient #F1 was prescribed and receiving anti-hypertensive medications, anti-seizure medications, hypothyroidism medication, and anti-reflux medication upon admission to the hospital. Further review of the physician's orders dated 12/29/14 revealed a change in Patient #F1's anti-seizure medication.
Review of the Multidisciplinary Master Treatment Plan for Patient #F1 revealed the following problems identified under Axis I (Psychiatric/Behavioral): #1) Suicidal Ideation and #2) Depressed Mood. Further review revealed the Axis III diagnoses as Seizure Disorder, Hypertension, Hypothyroidism, and GERD. Under Axis III, the following problem was listed: Seizure Disorder.
Review of the Plans of Care for Patient #F1 revealed the following care plans were initiated and updated as warranted: #1) Suicidal Ideations and #2) Depressed Mood. Further review of the medical record revealed no plans of care for the Axis III diagnoses of hypertension, hypothyroidism, seizure disorder, and GERD.
In an interview on 01/12/14 at 3:35 p.m., SF4Director of Clinical Services verified and confirmed Patient #F1 did not have Axis III care plans for hypertension, hypothyroidism, seizure disorder and GERD initiated or implemented since her date of admission, and Patient #F1 should have had Axis III care plans initiated and implemented upon admission to the hospital.

Patient #F2
Patient #F2 was a 50-year-old female admitted to the hospital on 01/02/15. Axis I Diagnoses included Bipolar Disorder, Manic. Axis III (Medical) Diagnoses included Hypertension (High Blood Pressure), High Cholesterol, and Diabetes Mellitus, Type II (DM II).
Review of the Initial Care Orders dated 01/02/15 revealed the Axis I Diagnosis as Mood Disorder, and the Axis III Diagnoses of Hypertension, High Cholesterol, and DM II.
Review of the History and Physical dated 01/03/15 revealed the Axis III Diagnoses of Hypertension, High Cholesterol, and DM II.
Review of the Psychiatric Evaluation dated 01/03/15 revealed the Axis III Diagnoses of Hypertension, High Cholesterol, and DM II.
Review of the Initial RN (Registered Nurse) Assessment dated 01/02/15 revealed the Axis III diagnoses of Hypertension, High Cholesterol, and DM II.
Review of the Medication Reconciliation Sheet (home medications patient was taking prior to admission to the hospital) revealed Patient #F2 was taking Benicar (anti-hypertensive), 40/25 mg (milligram) once daily; Metformin (anti-diabetic) 1000 mg twice a day; Lantus insulin (anti-diabetic) 20 units injected every night at hour of sleep; and Crestor (anti-cholesterol) 10 mg every day.
Review of the physician medication orders revealed Patient #F2 was prescribed and receiving anti-hypertensive medications, anti-diabetic medications, and anti-cholesterol medication upon admission to the hospital, and was receiving capillary blood glucose (blood sugar readings) four times per day. Further review of the physician's orders dated 01/05/15 revealed a change in Patient #F2's anti-hypertensive medication and her anti-cholesterol medication.
Review of the Vital Statistics Record for Patient #F2 revealed elevated blood pressure readings on 01/02/15, 01/04/15, 01/05/15.
Review of the Multidisciplinary Master Treatment Plan for Patient #F2 revealed the Axis III diagnoses as Hypertension, High Cholesterol, and DM II. Further review of the Master Treatment Plan revealed the following problems identified under Axis I (Psychiatric/Behavioral): #1) Bipolar, Manic. Under Axis III, the following problems were listed: Hypertension, High Cholesterol, and DM II.
Review of the Plans of Care for Patient #F2 revealed the following care plans initiated and updated: #1) Altered Thoughts and #2) Knowledge Deficit Concerning Mental Illness. Further review of the medical record revealed no plans of care for the Axis III diagnoses of Hypertension, High Cholesterol, and DM II.
In an interview on 01/12/14 at 3:35 p.m., SF4Director of Clinical Services verified and confirmed Patient #F2 did not have Axis III care plans initiated or implemented since her date of admission, and Patient #F2 should have had Axis III care plans initiated and implemented upon admission to the hospital.

Patient #F3
Patient #F3 was a 60-year-old male admitted to the hospital on 12/19/14. Axis I Diagnosis included Mood Disorder. Axis III (Medical) Diagnosis included Hypertension (High Blood Pressure).
Review of the History and Physical dated 12/20/14 revealed the Axis III Diagnosis of Hypertension.
Review of the Psychiatric Evaluation dated 12/20/14 revealed the Axis III Diagnosis of Hypertension.
Review of the Initial RN (Registered Nurse) Assessment dated 12/19/14 revealed the Axis III diagnosis of Hypertension.
Review of the Medication Reconciliation Sheet (home medications patient was taking prior to admission to the hospital) revealed Patient #F3 was taking Hydrodiuril (anti-hypertensive), 25 mg (milligram) once daily; Lisinopril (anti-hypertensive) 20 mg once day.
Review of the physician medication orders revealed Patient #F3 was prescribed and receiving Clonidine (anti-hypertensive) 0.1 mg three times per day; Hydrodiuril (anti-hypertensive) 25 mg once daily; and Lisinopril (anti-hypertensive) 20 mg once daily, upon admission to the hospital. Further review of the physician's orders dated 01/0/15 revealed a change in Patient #F3's anti-hypertensive medication. Further review of the physician medication orders dated 12/23/14 at 11:00 a.m. revealed a change in Patient #F3's anti-hypertensive medication.
Review of the Multidisciplinary Master Treatment Plan for Patient #F3 revealed the Axis I Diagnosis (Psychiatric/Behavioral) as: #1) Schizoaffective Disorder and the Axis III diagnosis as Hypertension.
Review of the Plan of Care for Patient #F3 revealed the following care plans initiated and updated: #1) Low Self Esteem; #2) Altered Thoughts; and #3) Homelessness. Further review of the medical record revealed no plans of care for the Axis III diagnoses of hypertension.
In an interview on 01/13/14 at 12:15 p.m., SF4Director of Clinical Services verified and confirmed Patient #F3 did not have Axis III care plans initiated or implemented since his date of admission, and Patient #F3 should have had Axis III care plans initiated and implemented upon admission to the hospital.
In an interview on 01/13/14 at 12:45 p.m., SF4Director of Clinical Services and SF2DON (Director of Nursing) confirmed the above findings that Patients #F1, #F2, and #F3 did not have any Axis III plans of care developed, initiated, and implemented since their admission to the hospital.


Patient #F5
Review of the clinical record for Patient #F5 revealed the patient was a 17 year old male admitted to the hospital on 12/30/14 with diagnoses (Axis I) of Bipolar Disorder, Attention Deficit Hyperactive Disorder, Auditory Hallucinations, ISB (Inappropriate Sexual Behavior). Review of the record revealed the patient was admitted under a PEC (Physician Emergency Certificate) for dangerous to self, dangerous to others, and unable to seek voluntary admission.
Review of the physician's orders dated 01/02/15 revealed an order to send Patient #F5 to the medical clinic for evaluation of the left great toe. Review of the medical clinic progress note revealed the patient was diagnosed with Onychia (Inflammation of the nail bed) and Paronychia (Skin infection around nails) of the toe. Further review of the orders revealed antibiotics were ordered for 7 days, foot soaks were ordered three times a day for 15 minutes and an incision & drainage was ordered. Review of the physician's orders revealed the frequency of the foot soaks were decreased on 01/06/15 to bedtime only for 2 nights and discontinue.
Review of the Multidisciplinary Master Treatment Plan revealed no documented evidence that the medical diagnoses of Onychia and Paronychia along with the prescribed interventions were included in the treatment plan.

In an interview on 01/13/15 at 12:45 p.m., SF7RN and SF8Dir Adj Therapy (Director of Adjunct Therapy) reviewed the clinical record for Patient #F5 and confirmed the patient developed a medical problem during the current admission that required antibiotics and foot soaks. SF7RN and SF8Dir Adj Therapy confirmed the Master Treatment Plan was not updated to include the medical problem, but should have been.


2) Failing to include interventions to address all identified patient problems:

Patient #F5
Review of the clinical record for Patient #F5 revealed the patient was a 17 year old male admitted to the hospital on 12/30/14 with diagnoses (Axis I) of Bipolar Disorder, Attention Deficit Hyperactive Disorder, Auditory Hallucinations, ISB (Inappropriate Sexual Behavior), History of Aggression.

Review of the psychiatric evaluation revealed the patient indicated the reason for his admission was that he molested someone. Review of the physician orders dated 01/01/15 revealed a room change was ordered due to ISB by Patient #F5. Review of the orders dated 01/02/15 revealed the patient was placed on Visual Contact precautions for ISB (Inappropriate Sexual Behavior). The record revealed the patient remained on Visual Contact precautions until 01/11/15. Review of the MHT (Mental Health Technician) notes dated 01/01/15 and 01/04/15 revealed ISB by Patient #F5 was documented. Review of the MD (Physician) Progress notes dated 01/02/14, 01/04/15, and 01/05/15 revealed ISB by Patient #F5 was documented.

Review of the Master Treatment Plan revealed the only problems identified were Anger Management, Depressed Mood, and Altered Thoughts. Review of the interventions and goals, revealed no documented evidence of any interventions or goals that addressed the patient's ISB.

In an interview on 01/13/15 at 12:45 p.m., SF7RN and SF8Dir Adj Therapy (Director of Adjunct Therapy) reviewed the clinical record for Patient #F5 and confirmed the patient was admitted with ISB and had demonstrated incidents of ISB during the current admission. SF7RN and SF8Dir Adj Therapy confirmed the Master Treatment Plan did not include interventions or goals to address the ISB, but should have.


3) Failing to update the treatment plan to reflect changes in the patient's condition and the use of restraint/seclusion:

Patient #F4
Review of the clinical record for Patient #F4 revealed the patient was a 16 year old female admitted to the hospital on 12/12/14 with diagnoses of Mood Disorder, PTSD (Post Traumatic Stress Disorder), and Impulse Control Disorder. Review of the record revealed the patient was admitted under a PEC (Physician Emergency Certificate) dated 12/11/14 for dangerous to self and unwilling to seek voluntary admission after the patient locked herself in a room with a knife.

Review of the RN Progress Notes and the MHT Progress Notes from 12/29/14 to 01/12/15 revealed multiple entries of inappropriate sexual behavior, threatening behavior toward staff and peers, and aggressive behavior.

Review of the RN Seclusion and Restraint Notes revealed Patient #F4 was placed in Physical Restraint (Manual Hold) on the following dates:
12/29/14 at 10:15 a.m. to 10:20 a.m. for destroying property and threatening staff.
01/11/15 at 8:32 a.m. to 8:43 a.m. for verbally threatening staff. Patient was intrusive, cussing and making sexually inappropriate comments to staff.
Review of the RN Seclusion and Restraint Notes revealed Patient #F4 was placed in Locked Seclusion on the following dates:
12/14/14 at 6:10 p.m. to 7:25 p.m. for punching another client in the face.
01/11/15 at 8:45 a.m. to 9:12 a.m. for verbally threatening staff. Patient was intrusive, cussing and making sexually inappropriate comments to staff.

Review of the Multidisciplinary Master Treatment Plan revealed the Axis I Diagnoses were Mood Disorder, PTSD, Depression Unspecified, R/O (Rule Out) Bipolar Disorder, R/O Psychosis, R/O Adjusted Disorder with Depressed Mood. The Axis II Diagnosis was Anti-Social Traits.
Review of the Master Treatment Plan revealed the following problems were identified in the treatment plan on 12/17/14: Suicidal Ideation, Depressed Mood, and Peer/Sibling Conflict related to (left blank). Review of the goals and interventions for Peer/Sibling Conflict revealed the identified goals were checked: 2. Abide by rules of unit and speak calmly to all peers with respect. 3. Will list problems he/she has with sibling/discuss in group settings, and suggest concrete solutions with prompts and without prompts. The identified interventions included prescribe, monitor, adjust medications, group therapy, education groups and monitor patient's response to medications, monitor and record patient's mood, behavior, sleep and appetite pattern, provider daily direction as necessary, and offer frequent, brief, non-threatening contact to build trust. Review of the Master Treatment Plan revealed the only updates/revisions to the Master Treatment Plan for Peer/Sibling Conflict was, "Extend #2, work on rules, speak calmly."
There was no documented evidence the Master Treatment Plan was updated with the use of restraints and seclusion, and there was no documented evidence the plan was updated new interventions when the patient's inappropriate sexual behavior, threatening behavior, and aggressive behavior continued. There was no documentation in the Master Treatment Plan related to inappropriate sexual behavior, threatening behavior toward staff and peers, and aggressive behavior.

In an interview on 01/13/15 at 11:20 a.m., SF9RN confirmed she was the RN assigned to Patient #F4. After reviewing the clinical record for Patient #F4, SF9RN confirmed manual hold and locked seclusion were interventions used for the patient. SF9RN confirmed the patient's inappropriate sexual behavior, threatening behavior toward staff and peers, and aggressive behavior were not addressed in the Master Treatment Plan, nor was the use of restraint and seclusion.

In an interview on 01/13/15 at 11:30 a.m., SF4Dir (Director) Clinical Services stated Patient #F4's behavior was volitional and not a mental health issue. She stated the patient was still in the hospital due to placement issues and stated the patient needed a correctional facility. SF4Dir Clinical Services stated the focus is on protecting the staff and other patients from Patient #F4 and restraint/seclusion is a milieu management tool and not a treatment plan tool. SF4Dir Clinical Services stated the patient was not suicidal and stated she is Axis II and has a personality disorder and was a sociopath.

Review of the hospital's corrective actions related to the treatment plans revealed the hospital revised the Treatment Plan policy to ensure serious occurrences initiated a review of the current treatment plan and ongoing chart audits included review of the treatment plan to ensure the treatment plan was individualized and comprehensive.


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