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Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Philhaven Hospital failed to ensure the protection and promotion of the rights of patients by failing to provide care in a safe setting (0142)(0144).

Cross reference with:
482.13(c)(2) Patient Rights: The patient has the right to receive care in a safe setting.
482.13(c)(3) Patient Rights: The patient has the right to be free from all forms of abuse or harassment.

Based on a review of facility documents and staff interview (EMP), it was determined that Philhaven Hospital failed to maintain a safe environment for patients by failing to identify that a patient did not return to the Unit following an outdoor group activity.

Findings include:

A review of facility policy "Checks and Client Supervision" revealed "Policy: Client safety is a primary responsibility of staff. Each client will be assigned a level observation including frequency of checks by the Treatment Team based upon a clinical evaluation. The level of observation will be assigned by the Treatment Team and documented by a Physician Order in the client's medical record ... III. Procedure for checks: ... B. Client supervision: Staff will maintain an active awareness of the locations and activities of clients ...V. Procedure for Staff Supervision for Off Unit Activities: Staff must accompany clients on all off-unit activities. Staff will maintain an active awareness of the locations and activities of clients and the Physician Orders pertaining to movement and special observations ..."

MR21 revealed the following Physician Orders related to observation level:
05/12/20 at 1023. Level of Observation - Adult/EAU (extended adult unit) Only Safety Observation with 5 min checks; safety...
05/12/20 at 1412. Level of Observation - Adult/EAU Only 15 min checks; denies SI/HI, (suicidal ideation)(homicidal ideation), intent or plan, able to follow safety plan ...
06/16/20 at 1330. Level of Observation - Adult/EAU Only 5 min checks; for safety...
06/18/20 at 1225. Level of Observation - Adult/EAU Only 15 min checks; denies active suicidal or homicidal ideations, intent or plan ...
07/09/20 at 0933. Level of Observation - Adult/EAU Only 15 min checks; Level C; denies SI/HI, intent or plan, willing to follow safety plan, attending groups ...


Further review of MR21 revealed:

Progress Notes June 24, 2020. Summary of Session: (Include psychosocial elements/modifiable risk factors addressed in session)
Patient denied HI, A/VH, (audio/visual hallucination) but endorsed SI saying both, "I want to be put in a place and let go until I die. I wish I just had a big knife and could just cut myself and be done. It's ridiculous because nothing is helping and nothing will. ... ."

"... Date of service; July 24, 2020 4:53 PM ... At approximately 1415 staff called a medical emergency over the Walkie talkies to the pond on Philhaven property. Upon arrival, 4 staff were pulling ... (name redacted) out of the pond onto the bank and staff started CPR (cardiopulmonary resuscitation) immediately with chest compressions and rescue breaths with bag valve mask with O2 when it arrived at approximately 1420.
Client did not have a pulse when pulled out of the pond and remained pulseless through entire code. AED (automated external defibrillator) was applied at approximately 1420 and no shock was advised throughout the entire Code. Ambulance arrived at approximately 1430 who assisted with CPR until patient entered the ambulance. Staff who delivered CPR included the following RNs: ... ."

An interview was conducted with EMP7 On July 28, 2020 confirmed that the patient had the appropriate privilege level to leave the Unit with Staff supervision. Further interview revealed there was some confusion as to how many and which patients actually left the Unit on July 24th and how many patients returned to the Unit. The staff failed to notice that the patient (MR21) did not return to the Unit. All the patients who went outside were thought to be back on the Unit. The patient (MR21) was not identifed as missing for approximately 20 minutes.


Cross Reference:
482.13 Patient Rights

Based on a review of facility documents, Security camera recordings, medical records (MR), and staff interview (EMP), it was determined that Philhaven Hospital failed to maintain patient safety by neglecting to ensure the identification of and the number of patients that left the Unit for outdoor activities were the same patients that returned to the Unit.

Findings:

A review of facility policy "Checks and Client Supervision" revealed "Policy: Client safety is a primary responsibility of staff. Each client will be assigned a level observation including frequency of checks by the Treatment Team based upon a clinical evaluation. The level of observation will be assigned by the Treatment Team and documented by a Physician Order in the clients medical record ... III. Procedure for checks: ... B. Client supervision: Staff will maintain an active awareness of the locations and activities of clients ...V. Procedure for Staff Supervision for Off Unit Activities: Staff must accompany clients on all off-unit activities. Staff will maintain an active awareness of the locations and activities of clients and the Physician Orders pertaining to movement and special Observations ..."


An interview was conducted with EMP7 on July 29, 2020. EMP7 revealed the staff was not aware which patients actually went out with the group. The staff counted 11 people when leaving the Unit and 11 patients when returning to the Unit.

Surveyors requested to view any Security recordings available from July 24th. It was observed on review of the Security tapes that 12 patients left the Unit but only 11 patients returned to the Unit.



Cross Reference:
482. 13 Patient Rights

Based on a review of facility documents, medical records (MR) and interviews with staff (Emp) it was determined that Philhaven Hospital failed to address the patient's intercurrent disease processes and failed to address the patient's medical conditions on the Treatment Plan for one of one patient.

Cross reference:
482.61(a)(2) A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnosis of intercurrent diseases as well as the psychiatric diagnosis.
482.61(c)(1) Each patient must have an individual comprehensive treatment plan

Based on a review of facility documents, medical records (MR) and interviews with staff (EMP) it was determined that Philhaven Hospital failed to address the patient's intercurrent disease processes for one of one patient.

Findings:

WellSpan Philhaven Rules and Regulations for Medical Staff and other Clinical Personnel.
... III. Documentation of Patient Care. A documented medical record is to be maintained for each patient receiving treatment through a WellSpan Philhaven program. The clinical record is used to provide a means of communication among all staff members who contribute to the patient's treatment. ... A. Admission. 1. Inpatient. An initial assessment of the patients' medical condition shall be made by the admitting physician. A diagnostic impression, treatment plan and initial orders will be entered in the clinical record at the time of admission. ... B. General Medical Conditions. 1. Inpatient. A physician or certified nurse practitioner/physician assistant under the supervision of the physican shall complete a history & physical examination within 24 hours of admission. ... The following data elements comprise a comprehensive history & physical examination: Client name and age; vitals signs, chief complaint ... recent Medications, Diet ... ."


MR21 revealed Admission History and Physical, May 12, 2020: "... Chief Complaint: "My esophagus is sore, I cannot eat or drink. I am very weak. Patient stated that "I scalded my throat on Friday on hot tea" and now has difficulty swallowing, stating that "a lot of liquid is coming out" and believes that there is something wrong with their throat ... Patient also claims that "my mouth and stomach is full of Candida ... pain under my tongue and jaw ... I feel like lump of food there, I have to spit every so often"... Past Medical History: Anxiety, Depression, Diabetes mellitus, Iron disorder, and other medical diagnoses noted on admission which could have contributed to the patient's swallowing disorder ... Major Illnesses. Review of Systems: ... GI/GU ... Throat: Posterior pharynx clear without erythema, edema, or exudate. Small prom (prominent) right side of thyroid cart (cartilage). Does not feel consistent with thyroid nodule. Neck: Supple without anterior or posterior nodes. ... Past Psychiatric History: Patient reported that this is first psychiatric hospitalization, has never been hospitalized in psychiatry before. ... Patient is currently on Zyprexa, Zoloft and Klonopin. ... ."


Further review of MR21 revealed the following entries: May 14, 2020 at 7:57 PM. Patient became very dizzy and could not walk when nurse attempted to take orthostatic blood pressure. On Call Physician notified and two Ensures were ordered. Patient refused to eat or drink and stated "The lump in my throat is a blockage. ..." Staff sternly enforced patient to drink water and two Ensures. After several prompts patient complied. Patient requested an ultrasound of throat ... Patient hoarded multiple cups, forcing self to spit in them. Staff removed cups and encouraged patient to use toilet for uncontrollable regurgitation. Will continue to monitor ... .

Therapist Progress Note: of Session: July 1, 2020 Time of Session: 1500 ... Therapist complimented patient on attendance at groups. Patient replied, "therapy groups are just waste of time. Having self esteem or breathing doesn't make a difference in your throat, all of that is irrelevant. ... throat is not working very well. I'm not pooping actually at all. It's very discouraging." When Therapist noted that patient looks better and seems to be eating more patient said, "I've been eating this week like a normal person and it still isn't making a difference." When asked what would help patient know that their throat is working correctly, Patient replied, "A barium swallow study ..."

MR21 failed to reveal any documentation of further investigation of possible thyroid nodule noted on exam or any diagnostic studies to rule out a medical cause for patient's complaints of inability to swallow and failed to address the patient's history of other medical diagnoses noted on admission which could have contributed to the patient's swallowing disorder

Interview with EMP7 revealed that the facility was did not address the patient's swallowing issue because it was part of the patient's delusions and the facility was not aware of the some of the other medical diagnoses noted on admission which could have contributed to the patient's swallowing disorder until the discharge was being planned and one of the Outpatient Providers requested information related to the other medical diagnoses noted on admission which could have contributed to the patient's swallowing disorder.

It was noted that both medical problems were indicated on the patient's Admission History and Physical, dated May 12, 2020. (MR21)

Based on a review of facility documents, medical record (MR) and interviews with staff (EMP) it was determined that Philhaven Hospital failed to address the patient's medical conditions on the Treatment Plan for one of one patient.

Findings:

WellSpan Philhaven Rules and Regulations for Medical Staff and other Clinical Personnel. "... C. Treatment Plan. An individualized plan of treatment shall be prepared for each patient. The plan is to be based upon careful assessment of the patient staus which includes, the examination of medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects. This plan shall set forth the treatment goals and prescribe an integrated program of therapies, activities, experiences and education designed to meet these goals. The treatment plan is to be based upon collaborative recommendations of the patient's interdisciplinary team. To the extent feasible, the plan should be formulated in consultation with the patient. ... ."

The review of facility policy "Multidisciplinary Treatment Plan" revealed 'I. Purpose: The Multidisciplinary Treatment Plan is an important component and element of each client's medical record. The Multidisciplinary Treatment Plan serves to promote communication and collaboration among disciplines and reinforce an integrated, multi-faceted approach to a client's care, resulting in better clients outcomes. II. Policy: Each client must have an individual comprehensive treatment plan ... The treatment plan must be individualized for the client ... III. Definitions: ... Treatment Team: which includes the various disciplines: Psychiatry, Medical Physicians ..."

The review of MR21 Teatment Plan did not address the patient's concerns related to their swallowing issues and other medical diagnoses noted on admission which could have contributed to the patients swallowing disorder.

Interview with EMP7 revealed that the facility was did not address the swallowing issue because they believed it was part of the patient's delusions, and the facility was not aware of the other medical diagnoses noted on admission which could have contributed to the patient's swallowing disorder until the discharge was being planned and one of the Outpatient Providers requested information related to the other medical diagnoses noted on admission.

Both medical problems were included on the patient's Admission History and Physical dated May 12, 2020.