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Based on interviews and document review, the facility failed to ensure nursing staff re-evaluated and revised patient care plans to include safety interventions and the patient's response to those interventions in one of two medical records reviewed for patients with repetitive self-harming behaviors (Patient #14).

Findings include:

Facility policies:

According to the Treatment Planning Process policy, the treatment plan is the outline of what the hospital has committed itself to do for the patient based on an assessment of the patient's needs. The Interdisciplinary Treatment Plan includes the patient specific problems to be treated, short and long-term goals which can be objectively measured, active treatment modalities and interventions planned to help the patient meet the goals of hospitalization, and specific interventions and modalities by various named disciplines. The Interdisciplinary Treatment Plan will be updated at least every seven days and with significant changes to reflect the patient's goal progress.

According to the Nursing Assessment and Care Plan policy, nursing assessments are performed and care plans are developed by registered nurses. The following are considered nursing plans of care: Nursing notes and observations in the behavioral health intake unit; and nursing notes that reference planning, without regard to their placement in the medical record. The nursing plan of care may include referrals to other disciplines based on the assessed needs of the patient. Patients should be reassessed by a registered nurse when there are significant changes in the patient's condition and at least every 12 hours. An interdisciplinary treatment plan is required for patients in the inpatient behavioral health, and treatment plans made by nursing staff are understood to include the nursing care plan as a component of the interdisciplinary treatment planning process.

Reference:

According to Lippincott Guidance, which was referenced by the facility for nursing standards and processes, in the Lippincott Manual of Psychiatric Nursing Care Plans (Videbek, S. & Schultz, J., 2013, pp. 4-5 and 35-36, retrieved from: https://dl.uswr.ac.ir/bitstream/Hannan/ 138867/1/9781609136949.pdf) it read, the use of written care plans can enhance the consistency and effectiveness of nursing care. The benefits of using written care plans include: increased communication among nursing staff and other members of the health care team; clearly identified expected outcomes and strategies; routine evaluation and revision of interventions; increased consistency in the effectiveness and delivery of nursing care.

Benefits also include if a nursing intervention is ineffective, it can be revised and a different intervention implemented in a timely manner. Written individual nursing care plans are necessary in the clinical setting because they provide the basis for evaluating the effectiveness of interventions, and allow revisions based on documented plans of care not unspecified or haphazard nursing interventions.

The nursing process includes assessment, formulation of diagnoses, determination of expected outcomes, identification of interventions which may lead to expected outcomes, establishment of a timetable to evaluate all parts of the process, and revision of each step when appropriate. Each part of this is specific to the person and must be determined for each client.

Implementation of care plans includes nursing interventions, also called nursing orders. Nurses are an integral part of the interdisciplinary treatment team and they collaborate in providing care and supporting goals, outcomes and interventions.

1. Nursing staff failed to re-evaluate and revise the patient care plan when the patient had significant events of self-harm occur and further failed to include safety interventions ordered by the physician (mitts) to ensure consistent implementation of the intervention and monitor the patient's response.

a. A review of Patient #14's medical record of 3/14/23 to 4/15/23 revealed Patient #14 was admitted to the adolescent unit on 3/14/23 for an attempted overdose of Lithium (a mood stabilizing medication).

According to the Psychiatric Initial Assessment completed on 3/15/23, Patient #14 was admitted to the facility following a suicide attempt and had a history of self-harming acts, including cutting, pulling her hair out, and scratching herself. The note read, Patient #14 required 1:1 staffing due to continued self-harming behavior.

A. Physician orders

i. On 3/15/23 at 4:26 p.m., an order was documented for Patient #14 to be placed on a 1:1 observation (one staff member providing constant and direct observation to one patient) due to self-harm behaviors, primarily from scratching herself and inflicting wounds. The order further instructed that the patient may have required 2:1 observation (two staff members providing constant direct observation to one patient) at night due to excessive acts of self harm.

Between the dates of 3/15/23 and 4/15/23 Patient #14 was monitored by staff on a 1:1 observation and had 13 incidents of self-harm during that time, one which required her to be transferred to a medical center for treatment. There was no documentation the staff implemented the 2:1 observations outlined in the order above.

ii. On 3/27/23 at 2:48 p.m., an order was documented which instructed staff to apply mitts if the patient was not able to resist picking, rubbing or scratching until the patient was able to be redirected.

B. The treatment plan was not updated after significant events occurred with Patient #14

i. According to the policy, the treatment plan was the outline of what the hospital had committed itself to do for the patient based on an assessment of the patient's needs.

ii. On 3/16/23, a Master Treatment Plan was created and signed by Registered Nurse (RN) #1. The Master Treatment Plan identified Patient #14 was a danger to herself due to suicidal ideation and self-injurious behavior.

iii. From 3/16/23 until 3/23/23, Patient #14 had six incidents of self-harm to include on 3/20/23 at 3:30 p.m., Patient #14 punched a wall which caused moderate swelling, bruising, and limited range of motion with a suspected fracture. The patient was then transferred to another facility for a medical evaluation.

iv. On 3/23/23 the Master Treatment Plan was revised. A new problem of Skin Alteration was added to the treatment plan, which read Patient #14 demonstrated newer behaviors of suicidal ideation in the form of self-harm via scratching, which required continued 1:1 monitoring.

According to the treatment plan the problem was evidenced by multiple visible skin alterations which were open and healing. The nursing interventions to address the problem were nursing staff were to assess wounds or skin impairments and treat as ordered, and the RN was to educate the patient on treatment protocols for skin alterations if ordered. The treatment plan was not revised to include interventions to address Patient #14's other self-injurious behaviors, such as punching a wall.

v. On 3/25/23 the day shift staff member noticed blood on Patient #14's pillowcase and blanket. Patient #14 stated the staff member who was her 1:1 overnight was not watching her, so Patient #14 self-harmed all night.

vi. On 4/4/23 at 8:46 p.m., Patient #14 began escalating and self-harming by hitting, scratching and biting herself. Patient #14 was assisted to the floor by two staff members due to the patient sliding out of her chair. She then began banging her head on the floor. A Code Gray was called at 8:58 p.m.

vii. On 4/5/23 at 7:50 p.m., a Code Gray was called due to Patient #14 self-harming which included banging her head on the wall and scratching/digging at her arms.

Interventions done by staff during the event included distraction, calm reassurance, deep breathing, letting the patient pace around the room while holding her hands, offering food, Boost and Gatorade. None of these techniques de-escalated the patient. Oral PRN medications were offered three times, however Patient #14 refused and continued to try to bang her head on the wall. Staff held her arms and hands so she could not continue to scratch and dig at herself and another staff member held a pillow between the wall and the patient's head so she would not cause injury to her head.

At 7:55 p.m. the on-call doctor was called. At 8:00 p.m. orders were received for restraint and emergency medications, and these were given at 8:25 p.m. At 8:40 p.m. Patient #14 stopped the behavior and went to bed quietly.

viii. On 4/6/23 Patient #14 was in her room and began scratching herself. Staff attempted to verbally de-escalate the patient however was not successful. Staff moved Patient #14's hands away to prevent her harming herself and mitts were utilized for approximately 45 minutes.

ix. On 4/8/23 Patient #14 was noted to have self-harmed with new scratches identified. When the RN assessed Patient #14, there were multiple wounds on her arms and one on her right thigh. Patient #14 stated her 1:1 the night before had watched her do this and did not stop her.

There were no additions, revisions or updates of any kind to the Master Treatment Plan between 3/23/23 and 4/15/23 despite the above events in which Patient #14 continued to self-harm. In addition, at no time during Patient #14's admission did the treatment plan include interventions to address Patient #14's other self-injurious behavior of banging her head on the floor and wall. This was in contrast to facility policy which read, the Interdisciplinary Treatment Plan was to include active treatment modalities and interventions by various disciplines, and was to be updated at least every seven days and with significant changes to reflect the patient's progress.

C. The treatment plan did not include mitts

i. The provider's order for mitts entered on 3/27/23 read, staff were to apply mitts if Patient #14 was not able to resist picking, rubbing, or scratching and until the patient was able to be redirected. Although a provider documented on 3/31/23 a discussion occurred with the team to reassess the patient's care plan and ensure mitts were implemented consistently, there was no evidence the Master Treatment Plan was updated to reflect the use of mitts as a safety intervention to address self-injurious behavior nor was there evidence the plan was re-evaluated following continued episodes of self-harm to monitor Patient #14's response to the use of mitts.

ii. On 3/25/23, the Advanced Psychiatric Nurse Practitioner entered a progress note which read, Patient #14 had an episode of scratching, soft mittens were applied,and she was able to keep herself safe since this incident.

iii. On 3/27/23, the order was entered by the Nurse Practitioner which read, apply mitts if patient is not able to resist picking/rubbing/scratching until the patient is able to be redirected.

The Nurse Practitioner's progress note on this date read, Patient #14's self harm was escalating and she had to be redirected several times to stop, including using mitts to inhibit her ability to self-inflict wounds. According to the note, 1:1 monitoring remained in place due to self-harming behaviors and mitts were to be used as an alternative to scratching if redirection was unsuccessful.

iv. There was no evidence in the medical record a revision or update was made to Patient #14's Master Treatment Plan to include the new provider order for mitts as an intervention to address self-harming behaviors and prevent injury to the patient. In addition, there were no updates to the Master Treatment Plan to reflect nursing staff reassessed Patient #14's treatment plan or identified additional interventions following continued and escalating self-harming behaviors.

v. Patient #14's medical record revealed multiple episodes in which nursing and ancillary staff did not implement mitts to prevent or address the patient's self-harming behavior according to the provider's order.

vi. On 3/31/23 an Advanced Psychiatric Nurse Practitioner entered a progress note which read, Patient #14 presented to the meeting with a scratch mark on her forehead and stated she felt overwhelmed the previous day and scratched herself. The Nurse Practitioner documented they discussed a plan with the team for consistency with placing mittens on the patient's hands when she self-harmed, and planned to present to the team the following day to reassess the plan of care.

There was no documentation in the nursing notes from the previous day, 3/30/23, to reflect mitts were implemented at any time during the day or night to prevent the patient from scratching herself.

vii. On 4/2/23 a Nursing Progress Note was entered which read, Patient #14 was agitated and made several attempts to self-harm in the evening. According to the note the patient was redirected multiple times from scratching and attempting to bite herself, and pulled the scab off of a wound in the center of her forehead causing it to bleed. The note read, Patient #14 was offered multiple medications for anxiety and agitation but refused. There was no evidence staff implemented the use of mitts to prevent self-injurious behavior when Patient #14 was unable to be redirected and injured her forehead.

viii. On 4/5/23 at 7:52 a.m. a Nursing Progress Note was entered which read, on the evening of 4/4/23 a Code Gray was called due to Patient #14 demonstrating self-harming behaviors of biting, scratching, punching and kicking herself. According to the note staff were unable to redirect Patient #14 after several attempts, she continued to try to self-harm. Staff then contacted the provider and received orders for emergency medications which were administered. There was no evidence at any time during this episode that staff implemented the use of mitts to prevent Patient #14 from self-injurious behavior.

ix. On 4/6/23 at 6:03 a.m. a Nursing Progress Note was entered which read, on the evening of 4/5/23 a Code Gray was called due to Patient #14 banging her head, scratching and digging at her arms. Despite de-escalation and distraction the patient continued to try and self-harm. Patient #14 was then restrained and emergency medications were administered. There was no evidence staff implemented the use of mitts when Patient #14 was scratching her arms either to prevent self-injury or to avert the need for restraint.

x. On 4/9/23 at 5:18 a.m. a Nursing Progress Note was entered which read Patient #14 approached the writer and showed her multiple new self-harm marks she had created. There was no further documentation to identify when the self-harm occurred and whether staff had attempted to implement mitts in order to prevent continued self-injury.

D. Interviews

i. Interviews revealed updates to treatment plans were to occur when there were significant events or changes which affected the patient's treatment, and it was important for staff to be aware of the updates in order to implement interventions and monitor progress.

Interviews further revealed according to facility policy, a review and update to Patient #14's Master Treatment Plan was warranted when the provider ordered mitts as an intervention to prevent self-injurious behavior, and when the patient had continued self-harming events.

Finally, according to staff and leadership interviews, it was important to review and update patient treatment plans to communicate new interventions to staff and ensure those interventions were implemented consistently. Patient #14's treatment plan was not updated to reflect the use of patient mitts to prevent episodes of self-harm, and as revealed by medical record review the intervention was subsequently not implemented consistently resulting in continued self-injurious behavior.

ii. On 4/12/23 at 12:03 p.m., RN #9 was interviewed. RN #9 stated when patient treatment plans were updated the changes were discussed with the team. She stated updates and discussion included next steps in the patient's treatment, interventions which worked and interventions which did not work.

iii. On 4/12/23 at 12:18 p.m., RN #10 was interviewed. RN #10 stated the treatment plan was important to address problems in the course of patient care. He stated the treatment plan was reviewed if there was an event or new needs identified, and the staff would review the plan and changes together. RN #10 stated mitts were to be implemented for Patient #14 if she did not respond to requests to stop harmful behavior.

iv. On 4/12/23 at 12:34 p.m., RN #11 was interviewed. RN #11 stated it was important to review and add to a patient's treatment plan, and she stated certain events might be a trigger to review the plan. She stated when the treatment plan was reviewed staff would meet to discuss the course of action.

v. On 4/17/23 at 1:37 p.m., the Assistant Director of Nursing (ADON) #4 was interviewed. ADON #4 stated nursing care plans were initiated at the time patients admitted, and updates were made to the care plan as staff began to know the patient better. She stated nursing staff initiated the Master Treatment Plan and the interdisciplinary staff reviewed it. ADON #4 stated the nurse was responsible to identify specific areas of the patient assessment, which could include self-harming behaviors or wounds, and ensure these problems were added to the treatment plan.

ADON #4 stated all staff needed to be aware of the Master Treatment Plan and participate in implementing the interventions included in the plan. She stated nursing staff provided oversight for the overall implementation of the plan. ADON #4 stated the nurse was responsible to monitor whether the patient was progressing with the elements identified in the treatment plan or if there were changes in the patient's course, as this was a key element in the development and staff discussions of the treatment plan.

vi. On 4/17/23 at 3:00 p.m., the Director of Nursing (DON) #3 was interviewed. DON #3 stated Patient #14 was a challenging patient due to her self-mutilation. He stated mittens were procured to apply to Patient #14's hands if she was self-harming with her hands. DON #3 stated the implementation of mitts should have been added to Patient #14's treatment plan because any new intervention in the patient's treatment should be added to the treatment plan, in order to ensure it was communicated to all team members. He stated if staff utilized an intervention which limited a patient's access to their body, this required addition to the treatment plan as it affected the patient's rights.

The interviews were in contrast to review of Patient #14's medical record. After the provider placed an order for mitts to be utilized if Patient #14 was self-harming and could not be redirected, there was no evidence her Master Treatment Plan was updated to include the use of mitts to ensure staff were aware and knowledgeable of the intervention. The medical record did not contain documentation that nursing staff monitored the use of mitts and Patient #14's response to the intervention in order to ensure the treatment plan was successful in addressing identified problem areas. Further review of the medical record revealed there were multiple documented events in which Patient #14 either attempted or succeeded to injure herself but staff failed to implement the use of mitts according to the provider's order.

E. Patient safety events

i. Review of patient safety events which involved Patient #14 revealed after 3/27/23, when the provider placed an order for mitts, there were continued episodes in which Patient #14 was able to injure herself, required administration of emergency medications, or required restraint due to self-harming behaviors. In the documented follow-up actions for one of these events staff wrote on 3/29/23, Patient #14's treatment plan was to be updated to include the order and use of mitts. However, there was no evidence in the medical record the update to the treatment plan occurred following these patient safety events to ensure staff were knowledgeable of the use of mitts and consistently implemented this intervention to prevent further harm.

In the follow-up documented for a later event involving Patient #14 staff wrote on 4/7/23, the patient continued to repeatedly self-harm, there was no mention of mitts being utilized when she was self-harming, and the team questioned whether or not the mitts were being used consistently.

This was in contrast to facility policy, which read the treatment plan was to include active treatment modalities and interventions and was to be updated at least every seven days and with significant changes. This also conflicted with interviews with nursing staff and leadership who stated treatment plans should be updated to address significant events or new patient needs, and nursing staff were responsible to ensure the treatment plan was implemented and interventions were monitored for success.