HospitalInspections.org

Based on interview and record review, the Hospital failed to ensure for 1 of 1 Security Staff (Security Staff #1) that they were trained in cardiopulmonary resuscitation (CPR) and first aid, and failed to ensure for 2 of 2 clinical staff (Mental Health Counselor #1 and Social Worker #1) that they were trained in first aid, as part of their restraint qualifications.

Findings include:

The Surveyor interviewed the Human Rights Officer at 1:00 P.M. on 3/15/17. The Human Rights Officer said that Security Staff, Mental Health Counselors and Social Workers participated in the application of soft restraints and chair restraints to patients. The Human Rights Officer said he believed that Security Staff, Mental Health Counselors and Social Workers had been trained in CPR, but not in first aid.

At the time of Survey there were no Security Staff present to interview regarding CPR and first aid training.

Security Staff Member #1's education and training file indicated there was no first aid or CPR documentation.

The Surveyor interviewed Mental Health Counselor #1 at 12:20 P.M. on 3/15/17. Mental Health Counselor #1 said she had been trained and certified in CPR, but not first aid.

Mental Health Counselor #1's education and training file indicated there was no first aid documentation.

The Surveyor interviewed Social Worker #1 at 12:25 P.M. on 3/15/17. Social Worker #1 said she had been trained in CPR, but was unsure if she had been trained in first aid.

Social Worker #1's education and training file indicated there was no first aid documentation.

Based on record review and staff interview, five (5) of eight (8) Master Treatment Plans (Patients 2, 4, 5, 15 and 17) included deficient outcome patient goals. Goals were stated in non-measurable terms, as treatment compliance and/or were not realistic for current hospitalization. These failures in goal statements hinder the ability of the team to individualize treatment and to measure changes in the patient consequent to treatment interventions.

Findings include:

A.Patient Findings:

1. Patient 2:

Treatment plan dated 3/9/17

a. For Problem, "Depression as evidenced by poor sleep, SI (suicidal ideation), mood swings, unable to cope," the long term goal was stated as "Alleviate depressive symptoms and return to previous level of effective functioning as evidenced by maintain ability to effectively parent child and maintain social relationships + (and) stable mood/safety x 6 months."

This goal was not stated in behavioral outcomes and was not realistic as it would be non-measurable during hospitalization.

b. For Problem, "Med (medication)-noncompliance as evidenced by off meds (medications) x 1 year," the long term goal was stated as "Maintain med (medication) compliance and verbalize needs to outpatient psychiatrist as evidence by take all meds (medications) as prescribed for one year."

This goal was not realistic as it would be non-measurable during hospitalization.

2. Patient 4:

Treatment plan dated 3/9/17

For Problem, "Suicidal thought as evidenced by report persistent thoughts of SI/SIB (suicidal ideation/self-injurious behavior)," the long term goal was stated as "Alleviate SI, maintain safety as evidenced by no SI/SIB (suicidal ideation/self-injurious behavior) x 1 year."

This goal was not realistic as it would be non-measurable during hospitalization.

3. Patient 5:

Treatment plan dated 2/23/27 with revision date of 3/6/17

a. For Problem, "Med (Medication) non-compliance as evidenced by stopped meds. (medications), brother states [s/he] is selling them," the long term goal was stated as "Maintain treatment compliance as evidenced by taking all meds (medications) as prescribed, regular attendance with outpatient providers x 6 mos. (months)."

This goal was not realistic as it would be non-measurable during hospitalization.

b. For Problem, "Paranoid delusions as evidenced by states [his/her] sister "took [his/her] personality," the long term goal was stated as "Maintain effective level of functioning as evidenced by reduction in paranoia and delusions, ability to maintain reality based thoughts x 1 yr. (year)."

This goal was non-measurable because it was not stated in behavioral outcome terms nor was it realistic as the goal would not be measurable during the patient's hospitalization.

c. For Problem, "Poor ADL's (Activities of Daily Living) as evidenced by no shower since admission, not sleeping," the long term goal was stated as "Maintain healthy lifestyle as evidenced by complete ADLs daily x 1 year."

This goal was not realistic as it would be non-measurable during hospitalization.

4. Patient 15:

Treatment plan dated 3/11/17

a. For Problem, "Substance Abuse as evidenced by relapse on alcohol," the long term goal was stated as "Maintain sobriety as evidenced by no substance abuse x 1 year,"

This goal was not realistic as it would be non-measurable during hospitalization.

before Problem, "Depression as evidenced by increased grief, increased anxiety," the long term goal was stated as "Alleviate depressive symptoms and return to previous level of effective functioning as evidenced by maintain housing, stable mood and stable relationships x 1 year."
This goal was not stated in behavioral outcome terms and was not realistic as it would be non-measurable during hospitalization.

A short term goal was stated as "work through grief and improve mood as evidenced by participate in 3 grief and loss groups and/or 1:1 sessions."
This was a treatment compliance statement, rather than a behavioral outcome that evidenced that the problem has been reduced/resolved.

5. Patient 17:

Treatment plan dated 3/8/17

a. For Problem, "SIB (self-injurious behavior) as evidenced by head banging, scratching, strangulation," a long term goal was stated as "No SIB (self-injurious behavior) or SA (Substance Abuse) X 1 year."

This goal was not realistic as it would be non-measurable during hospitalization.

b. For Problem, "Depression as evidenced by +SI (positive suicidal ideation) with plan, depress/flat affect," the long term goal was stated as "Maintain effective functioning as evidenced by completing GED, having own space, EMT certification."

This goal was not realistic as it would be non-measurable during hospitalization. In addition this goal addresses substance abuse which was not identified as part of the stated problem.


B.Staff Interview:

During interview with focus on the review of Treatment Plans as described in Section A. above on 3/13/17 at 4:30 p.m. the Director of Social Work acknowledged that some treatment goals were non-measurable or unrealistic for the patient during current hospitalization.

Based on medical record review, hospital policy review and staff interview, the facility failed to develop Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (2, 4, 5, 6, 15, 16, 17 and 18) that consistently included individualized treatment interventions with a specific focus and frequency. Many of the interventions on the treatment plans were listed as generic discipline functions/tasks. Failure to clearly describe specific modalities on patients' MTPs resulted in Treatment Plans that did not reflect a comprehensive, integrated, individualized approach to treatment.

Findings include:

A. Hospital Policy Review:

The facility policy titled "Protocol for the Use of the Multidisciplinary Format," last revised 2/1/17, stated under heading "Problems, Goals, and Interventions," "Interventions which reflect the care provided will be identified for each goal."..."The intervention will have an identified staff member and discipline, and each discipline should be reflected within the MDTP [Multidisciplinary Treatment Plan], collectively, but not necessary for each goal." The policy did not consistently discuss including the specific focus or frequency of each intervention.


B. Medical Record Review:

1. Patient 2:

Treatment plan dated 3/9/17

a. For the Problem of "Depression as evidenced by poor sleep, SI [suicidal ideation], mood swing, unable to cope," the following two interventions did not include a frequency: OT [occupational therapist]: "Provide education on development of coping skills through group therapy and 1:1 [one to one] counseling," and OT and MHC [Mental Health Counselor]: "Intro [introduction] to sensory, mindfulness and wellness. MHC- "Identity activities for self-care."

b .For the Problem of "Med-non-compliance as evidenced by: Off meds x [times] 1 year. Stated 'I stopped taking my meds when they don't work fast enough'."

2. Patient 4:

Treatment plan dated 3/9/17

For the Problem of "Suicidal thoughts as evidenced by reports persistent thoughts of SI/SIB [suicidal ideations/self-injurious behavior]", this intervention lacked frequency. MHC- "Provide suicide education on development or coping skills through group therapy and 1:1 counseling." This intervention lacked focus and frequency: OT& MHC: "Intro to sensory mindfulness & wellness."

-"Monitor SI daily." This generic intervention lacked focus.

- "Provide daily 1:1 supportive counseling." This generic intervention also lacked focus.

3. Patient 5:

Treatment plan dated 2/23/27 with revision date of 3/6/17

For the Problem of "Med non-compliance as evidenced by: Stopped meds, brother states s/he is selling them": A generic social work (SW) intervention without focus or frequency was "Identify community support." Nursing interventions without frequency was "Education, home med management, med education." Generic nurse practitioner intervention without focus or frequency was "Pharmacological Eval."

4. Patient 6:

Treatment plan dated 3/10/17

For the Problem of "Medication non-compliance as evidenced by disorganized thought process, & self-dialogue." Generic MD(physician) intervention was "Medication Evaluation," which also lacked a focus or frequency.

A generic nursing intervention that lacked frequency was "1:1 staff check-in to provide support and realty testing."

5. Patient 15:

Treatment plan dated 3/11/17

a. For the Problem of "Substance abuse as evidenced by relapse on alcohol," a nursing intervention which lacked frequency was "Provide education on relapse prevention through groups and 1:1 counseling." OT intervention that lacked a focus or frequency was "Intro to sensory, wellness & mindfulness."

b. For the Problem of "Depression as evidenced by increased grief, increased anxiety" that lacked frequency" was MHC-"Provide education on grief and loss through groups and 1:1 counseling."

6. Patient 16:

Treatment plan dated 3/8/17

For the Problem of "Disorganized thought process as evidenced by self dialogue, bizarre statements," a MD generic intervention without focus and frequency was "Med eval."

Nursing interventions lacking frequency were: "Staff check-in 1:1 q shift to monitor thoughts contrast and other reality testing," and "Education on illness management and coping skills to help with psychotic symptoms."

SW [Social Worker]: "Setup outpatient appointment" was a generic intervention that lacked focus.

Nursing intervention: "Med education via med education groups and illness management and coping skills to manage symptom" lacked frequency.

7. Patient 17:

Treatment plan dated 3/18/17

a. For the Problem of "SIB (Self injurious behavior) as evidenced by head banging, scratching, strangulation," the generic interventions without frequency or specific focus were:

Nurse practitioner: "1:1 observation."

Nursing: "Monitor, assess, report on behavior.Initiate safe plan."

OT [Occupational Therapy}: "Intro to sensory & mindfulness."

An intervention without frequency was nursing: "Provide education on the development of coping skills through group therapy & 1:1 counseling."

b .For the Problem of "Depression as evidenced by + (positive) suicide with plan, depressed/ flat affect," some generic interventions without focus were:

Nurse practitioner: "Pharmacological Eval, med education."

Nursing: "Provide frequent 1:1 check-ins and education on asking for help."

An intervention without frequency was nursing: "Provide education on identifying triggers through groups and 1:1 counseling."

8. Patient 18:

Treatment plan dated 3/11/17

For the Problem of "Depression as evidenced by mood lability and altercation with girlfriend," a SW generic intervention was "Contact aftercare programs to help patient with mood symptoms and learn coping skills."

A nursing intervention which lacked frequency was "Education on coping skills and relaxation techniques in groups."

A generic MD intervention without focus or frequency was "Medication Evaluation."

C. Staff Interview:

a. During interview with the focus on treatment plans as described in Section B, above on 3/13/17 at 4:50 p.m. with the Medical Director, he acknowledged that the physician interventions were generic.

b.In a telephone interview on 3/14/17 at 9:23 a.m., the generic interventions on the MTPs, which also often lacked focus and frequency, were discussed with the Nursing Director. She stated she was aware of the problem and they were working on fixing it.