HospitalInspections.org

Based on observation, staff and patient interview, the hospital failed to ensure privacy in 1 of 4 sampled female bathrooms on the Intensive Care Unit (#27).

The findings:

On 12/17/12 at approximately 10:52am, an observation of four female bedrooms on the Intensive Care Unit (ICU) was conducted with Staff #D. All bedrooms had a private bathroom. A privacy curtain was utilized in lieu of a door to separate the bedroom from the bathroom. A second privacy curtain separated the shower from the toilet area in the the bathroom. Both privacy curtains were missing in Patient #27's room. An interview was conducted with Staff D during the observation. Staff D was unsure why the room was missing both privacy curtains.

On 12/17/12 at approximately 4:30pm, Staff H stated that Patient #27 was taking a shower. The patients bedroom door was open, and it was obvious that Patient #27 was not in her own shower. Staff H stated that Patient #27 was taking a shower in another patient's room. At approximately 5:10pm, an interview was conducted with Patient #27. Patient #27 stated that there was no shower curtain in her room.

Follow-up observations were conducted on 12/18/12 at approximately 10:56am and 12/19/12 at approximately 11:00am. There were no privacy curtains in the bathroom or between the bathroom and the bedroom in Patient #27's room.

On 12/19/12 at approximately 11:00am, an interview was conducted with the Director of Plant Operations and the Housekeeping supervisor. The staff were asked about the missing privacy curtains. Neither staff was aware that Patient #27's room was missing the privacy curtains.

Based on observation, staff and patient interviews, clinical record review and review of the staffing schedule, the facility failed to staff the Behavioral Intensive Care Unit with adequate numbers of personnel to provide nursing care to all patients as needed for 5 of 5 sampled patients (#24, 25, 26, 27 and 28). Patients were observed to have behaviors without staff intervention and patients were in need of assistance with Activities of Daily Living and dining.

The findings:

On 12/19/12 at approximately 8:38am, an interview was conducted with the Admissions Director regarding the types of patients admitted to the Behavioral Intensive Care Unit (ICU). The director stated that patients placed on the ICU were typically low functioning with active suicidal thoughts that they were assessed as likely to act on. The more aggressive patients were also placed on the ICU. Patients who were not able to maintain themselves and were likely to act out, even without being provoked were admitted to the ICU.

A review of the staffing schedule revealed that only three people were scheduled on the ICU unit for day shift on 12/17/12. The day before, only 2 technicians were scheduled. The house supervisor was also the acting Registered Nurse for the unit.

Observations were conducted on the Behavioral Intensive Care Unit (ICU) beginning at 10:10am on 12/17/12 and continuing throughout the day. There were 14 patients on the unit. The staff included two nurses (Staff #D and E) and one mental health tech (Staff #C). The staff were observed to be on the floor meeting patient needs for the majority of the day. Staff had only occasional breaks to complete paperwork, and were rarely in the nurse's station. Even with staff diligence, the numbers were inadequate to meet the needs of the patients.

On 12/17/12 at approximately 12:21pm, an interview was conducted with the only Mental Health Care Tech, Staff C, regarding her duties and care and services required by the patients. Staff C stated that she assists with personal care, takes vital signs, and helps the patients with dressing. She also delivers food trays, provides patient beverages throughout the day, changes beds, cleans-up on the unit as needed and intervenes as necessary for behaviors. She checks on every patient every 15 minutes, and documents this. (There were 14 patients currently admitted, and she was documenting on each every 15 minutes). Staff C was asked about patients requiring assistance. Staff C stated that Patient #24, #25, #26, #27, #28 and an unsampled patient need help with ADLs and that #24, #26, #27 and #28 had frequent behaviors that required 2 or more staff to assist.

Patient #24

Patient #24 was also observed without footwear at about 10:52am on 12/17/12. Patient #24 stated that they won't give me my socks. They are in the dryer. Patient #24 continued to be barefoot without any socks or shoes at 3:34pm. At approximately 4:16pm, Patient #24 was still asking staff for his socks.

On 12/17/12 at approximately 1:55pm, Patient #24 was observed to have a sudden mood change for no obvious reason. Patient #24 became loud and aggressive, was threatening staff. Patient #24 stripped all of his clothes off and started to run around on the unit spitting on staff. Staff were able to intervene, but had to call for assistance.

Patient #25

On 12/17/12 at approximately 10:10am, an interview was conducted with Patient #25. Patient #25 was complaining about a lack of assistance. She stated that she could not reach her bottom to wipe it, and no one would help her. I have a fall risk arm band, but they leave me alone in the shower. The night staff won't help me get up out of bed. I have to wet myself at night. They won't help me to the bathroom. There are no bedrails and the beds are low, and I cannot get up without help. I'm okay once I get up. My feet are cold because I have no socks on my feet. I can't reach my feet to put my socks on. Patient #25 was observed to be holding a pair of red non-skid socks. Immediately after this statement, another patient began to assist her with the socks, and then a staff member assisted with the other foot.

On 12/17/12 at approximately 12:21pm, an interview was conducted with the Mental Health Care Tech, Staff C. Staff C confirmed that Patient #25 needs at least two people to assist her out of bed in the morning. She has trouble getting out of bed. In the morning, her bed will be saturated with urine, and I have to change it. She does fine during the day.

On 12/17/12 at approximately 11:10am, a follow-up interview was conducted with Patient #25. Patient #25 stated that she had a cut on her right leg. An observation revealed a 2 inch by 2 inch abrasion on her right leg. There was no dressing. A subsequent record review revealed a physician's order dated 12/16/12 for a dry sterile dressing to be applied twice a day.

Patient #26

On 12/17/12 at approximately 10:52am, Patient #26 was observed to be wearing a blue paper shirt that was ripped in the back exposing about 12 inches of skin. The patient was walking around barefoot - without any socks or footwear. Patient #26 stated that his clothes got wet and he went swimming in the bed. Staff #C confirmed that Patient #26 likes to get in the shower with all his clothes on then belly flop in the bed. His clothes were in laundry. Patient #26 was observed to still be wearing the same ripped shirt at 3:34pm - still showing about 12 inches of his back from the tear in the shirt, and still without footwear.

On 12/17/12 at approximately 3:38pm, an observation of a patient assault was conducted. There were no staff visible on the unit during the assault and no staff intervened. Patient #26 was observed to be escalating in agitation and behaviors beginning at approximately 3:34pm. Patient #26 was pacing on the unit in his same ripped shirt, but wearing no pants and no underwear. Staff F and G spoke to him, and took him to his bedroom. About a minute later, Patient #26 was observed again in the day room. He remained naked from the waist down, and was yelling and banging on the glass at the nurses station. Staff G again assisted Patient #26 to his room. About 3:38pm, Patient #26 returned to the day room carrying a pillow. No staff were observed on the unit or in the area. Patient #26 assaulted an unsampled patient by slamming him forcefully in the face with the pillow. The unsampled patient got up to retrieve his eyeglasses that had landed on the floor, and Patient #26 got in his face yelling, posturing and looking for a fight. The unsampled patient de-escalated the situation. Patient #26 walked off, began pacing around the room, and then started banging on the Nurse's station window again and yelling. The patient kept repeatedly banging and stripped naked. Staff H entered the nurse's station. Staff H was documenting the 15 minute checks on her clipboard. Staff H saw the patient banging and heard him yelling, but was unaware that he was naked because of multiple memo's posted on the glass blocked her view. A second staff (staff F) then arrived, and asked where the other tech, Staff G was. Staff H stated that he went to the adolescent unit to try and find Patient #28 some clothes to wear. (Patient #28 was observed to be wearing a paper gown that was way too big for her. She was having to physically hold up the pants to prevent them from falling to the ground). When Staff G returned at approximately 3:45pm, Patient #26 was given an injection of prn (as needed) medication for behavior management. Patient #26 received an injection of Haldol (antipsychotic), Ativan (for aggression) and Cogentin (prevents side effects).

A record review was conducted on 12/18/12 for the nursing assessment leading to the above injection for Patient #26. The nurse did not document any specific information regarding the patient's behaviors. On 12/17/12 at 10:35pm, the nurse documented that the patient received prn Haldol and Ativan for agitation and threatening other patients, and that it was effective.

Further record review revealed that Patient #26 again received Haldol, Ativan and Cogentin at 11:35pm. There was no corresponding documentation for assessment of need or effectiveness.

Patient #27

On 12/17/12 at approximately 10:10am, an interview was conducted with Patient #27. Patient #27 stated that she recently underwent back surgery, and still had staples in her back. This was observed. Patient #27 stated that she has removed 2 staples herself with a pencil. Patient #27 stated that the staff are not assisting her as needed with Activities of Daily Living (ADLs).

A clinical record review of nursing assessments was conducted for Patient #27 on 12/19/12. There were no documented assessments of the surgical site on 12/15/12, 12/16/12 or 12/17/12.

On 12/17/12 at approximately 12:50pm, Patient #27 was observed to have a large wet area in the crotch of her pants. No staff were observed to notice this, or assist her in changing clothes. At about 2:28pm, Patient #27 was observed to be wearing the same pair of pants.

Patient #28

On 12/17/12 at approximately 12:21pm, an interview was conducted with the Staff C. Staff C stated that Patient #28 needs assistance with ADLs, and that she will fight you. Patient #28 was observed to stay in bed the morning of 12/17/12 from about 10:10am until lunch at 12:37pm. Patient #28 was assisted to walk to the dining room by staff. Patient 328 was a bit unsteady on her feet.

On 12/18/12 beginning at approximately 8:49am, a breakfast observation was conducted. Patient #28 was observed walking to breakfast with staff assistance. She was very unsteady on her feet, and her pants were saturated with urine. Staff C noted the condition of her clothes, and assisted Patient #28 back to her room to get cleaned up. Patient #28 lost her balance while turning around, but Staff C was able to prevent a fall.

After lunch at about 2:00pm, an observation was made of Patient #28 in bed. Staff C stated that the nurse wanted her to stay in bed because she was so unsteady on her feet. They were looking for possible causes.

On 12/17/12 at approximately 1:55pm, Patient #28 was observed in the day room wearing a paper shirt and pants that were way too large for her. Patient #28 was physically holding her pants up to keep from exposing herself, which intermittently she did. At approximately 3:45pm, (when Patient #25 had his behavior) Patient #28 was observed to still be wearing paper pants that were way too large. An interview was conducted with the charge nurse, Staff F, during the observation. She stated that the mental health technician was off the unit trying to find some clothes that fit Patient #28.

Lunch Observation:

A lunch observation was conducted on the ICU beginning at approximately 12:37pm on 12/17/12. Staff C was observed to bring the lunch trays onto the unit. Staff C stated that the nurse did the 15 minute checks while she went and got the food from the kitchen. Lunch consisted of Lorna Doone cookies, barbeque chicken (dripping with sauce), greens, roll, and sweet potatoes. The ladies trays were delivered first. Patient #28 was assisted to walk to the dining room by staff. The trays were served. No one was given a napkin. After the trays were handed out to the ladies, staff left the room and took the remaining trays to the gentlemen who were on a separate locked wing. The ladies were left without anyone monitoring the meal or providing assistance - or refills of beverages.
Patient #28 only ate the cookies a few bites of greens and a couple of bites of the sweet potatoes. Then she got up and left the room, a bit unsteady on her feet. No staff was available to sit in room with them or monitor the meal. No one encouraged Patient #28 to eat. An interview had been previously conducted with Staff D on 12/17/12 at approximately 10:52am regarding patient #28. Staff D stated that Patient #28 was a brittle diabetic.

On 12/17/12 at approximately 1:00pm, an interview was conducted about lunch with Patient #27. Patient #27 stated that they had no napkins with lunch. She cleaned her hands by licking her fingers. Patient #25 was observed to obtain a roll of toilet paper and use it as a napkin.

Clean and Sanitary Environment:
On 12/17/12 beginning at approximately 10:52am, observations were conducted of the Behavioral Intensive Care Unit (ICU). On the female side, the floor had dried spills, debris and food particles to include cheerios. The chairs appeared dirty with ground in dirt and had dried spills on the sides, backs and armrests. On the male side, there was an odor of urine and popcorn on the floor. The floor on both the female and male sides had dried dirt and grime in the grain especially near the walls, around the edges and in the dining areas. The dirt was removable with soap and water.

During the observation, Patient #24 was observed walking around barefoot. Patient #24 stated, "They won't give me my socks. They are in the dryer." The soles of Patient #24's feet were blackish with dirt.

On 12/17/12 at approximately 11:10am, an interview was conducted with Patient #25. Patient #25 stated, that the "floors are filthy".

On 12/17/12 at approximately 1:00pm, an interview was conducted with Patient #27. Patient #27 stated that the "place is filthy" and "nobody cleans".

On 12/18/12 at approximately 7:23am, a follow-up observation was conducted on the Behavioral Intensive Care Unit. There continued to be debris on the floor including the popcorn on the men's side and the cheerios on the women's side. The men's Day Room smelled of urine. The chairs continued to appear dirty with ground in dirt and dried spills on the sides, backs and armrests. There was dried spinach on the day room table on the ladies side. (Patient #25 was observed to eat her lunch on that table the day before. Spinach was served with lunch).

On 12/18/12 at approximately 9:41am, Staff #J was heard to state that it stinks on the men's side.

On 12/18/12 at approximately 9:12am, Patient #25 was again observed to be walking around barefoot. The bottoms of his feet were black with dirt.

On 12/18/12 at approximately 7:34am, and interview was conducted with Housekeeping Staff #I. Staff #I stated that she wipes down the chairs, the tables, dust mops and damp mops once a day. The patient care staff cleans the tables between times.

On 12/19/12 at approximately 11:00am, an interview was conducted with the Director of Plant Operations and the Housekeeping supervisor. The staff stated that housekeeping staff work 7a-3pm daily, except on Mondays when housekeeping works until 8:30pm. Housekeeping will clean daily the common areas to include tables and chairs. The floors are dust mopped and mopped daily. The mental health techs are responsible for cleaning the tables between meals. The floors are deep cleaned quarterly at present. We have recognized a need to do this more frequently, and are looking to hire a person to deep clean the floors.


29722

Based on observation, staff interviews and review of facility's policy and procedure, the hospital failed to ensure Glucometers were cleaned in accordance with accepted professional standards (Center for Disease Control and Prevention) for infection control. The hospital also failed to maintain a clean and sanitary environment on the Behavioral Intensive Care Unit.

The findings include:

Glucometers:

1. On 12/18/2012, during a tour of the Behavioral Intensive Care Unit at approximately 11:30am, the Registered Nurse (R.N.) was in the process of performing a blood glucose check on patient #27. After obtaining a reading of the patient's blood glucose level, put it inside a black zippered pouch and placed into the basket sitting on the medication table. She did not clean or disinfect the Accucheck device. The R.N. stated that she believed the Accucheck was cleaned each night and a control was performed on it. (#27)

2. On 12/18/2012, during an observation in preparation for Medication Pass on the Adult Unit, beginning at approximately 12:15pm, the L.P.N. was observed to perform blood glucose testing for 3 different patients, (#15, #39, and # 25). The Accucheck device was sitting in a basket with packaged alcohol prep pads. The Accucheck device was used on each patient and not cleaned between each use.

3. On 12/18/2012 at approximately 12:27pm, the nurse performing the blood glucose testing sated that the Accucheck was cleaned eached night and they do a control on it.

4. On 12/18/2012 at approximately 12:38pm, an interview was conducted with the Cheif Nursing Officer. He stated that he believed the Accucheck was cleaned with soap & water and that it was cleaned everyday.

5. A review of the facility's policy titled "Glucometer Use and Quality Controls", dated 02/29/2012, Policy #: WT.003, indicates under "PROCEDURE: 1.0 Caring for your meter........1.2 Clean the outside of the meter with a damp cloth and mild/soap/deterent. Protect the test strip port and Smar Code Key base from moisture." "4.0 INFECTION CONTROL: 4.1 The purpose is to ensure that the correct cleaning and disinfecting of the monitor is followed to prevent the possible transmission of infectious organisms through the system....4.1.1 Both the (CDC) and JCAHO recommend that precautions be taken during all procedures where there is a possibility of exposure to blood to clean the meter use alcohol. To disinfect dilute 1ml of bleach in 9 ml of water to achieve a 1:10 dilution."

Bleach would be an acceptable method of cleaning and disinfecting, however, the facility's current method of cleaning/disinfection and lack of cleaning in between each patient use, does not prevent or decrease the risk of cross-contamination of blood borne pathogens.

Based on observation, interview, record review, and policy review, the facility failed to:

I. Provide active treatment measures on the Intensive Care Unit (ICU) for 2 of 2 active sample patients (Patients 1-4, I-8) and 9 of 11 non sample patients on the unit (I-1, I-2, I-3, I-5, I-6, I-7, I-10, I-11, and I-13). The clinical staff was aware that these patients were not participating in their unit activities. There was no evidence that any of the patients were offered alternative therapies. Lack of active treatment results in patients being hospitalized without all interventions for recovery being provided to them, potentially delaying their clinical improvement. (Refer to B125-1)

2. Ensure that staff reinforce the importance of and responsibility for patients' attendance and participation in assigned treatment, and provide structured alternative treatment as needed in the Intensive Care Unit, affecting 2 active sample patients (Patients 1-4, I-8) and 9 non-sample patients (I-1, I-2, I-3, I-5, I-6, I-7, I-10, I-11, and I-13). This failure results in patients lying/sleeping in bed, sitting around and idly walking about the day room on the ICU. (Refer to B125 II)

Based on observations, medical record and hospital policy review, and staff interviews it was determined that the facility failed to provide active treatment measures on the Intensive Care Unit (ICU) for 2 of 2 active sample patients (Patients 1-4, I-8) and 9 of 11 non sample patients on the unit (I-1, I-2, I-3, I-5, I-6, I-7, I-10, I-11, and I-13). This failure results in patients not participating in selected interventions and possibly prolongs their hospital stay. The findings include the following:

I. Failure to ensure active individualized treatment on the Intensive Care Unit (ICU):

A. Observations

The ICU schedule lists 2 therapy groups available per day. Any patient with a Treatment Plan that has the modality "group therapy" as the method of treatment will be expected to attend, as that is all that is available.

1. On 12/17/2012 the "Process Therapy Group" was held from 11:30 AM to 12:30 PM. Although all patients were expected to go to group therapy, only 4 patients of the total 13 patients on ICU attended the group. Patient I-1 left the group within the first ten minutes after the start of the group.

2. On 12/17/2012 at 11:40 AM, accompanied by RN#1, it was observed that patients I-8, I-9, I-10, I-11 and I-13 were each in bed, and the patients I-3, I-4, I-5 and I-7 were either sitting in the day room or in bed sleeping instead of attending the scheduled group therapy.

3. On 12/17/2012 during the "Recreational Therapy Group" scheduled from 2 PM to 3 PM there were 4 patients who attended the group of the total 11 patients on ICU. Patients I-2, I-6, I-10, I-11 and I-13 were in bed. Patient I-3 was meeting with the physician; Patient I-8 was observed as agitated and pacing in the day room.

4. On 12/18/2012 the census had decreased to 11 patients. At 11:45 AM there were 3 patients (I-1, I-7, I-12) in the scheduled "Process Therapy Group." In the company of the DON the other 8 absent patients were located: Patient I-1, Patient I-2, Patient I-12 and Patient I-13 were each in their beds; Patient I-11 was walking in the hallway; Patients I-3 and I-4 were in the day room; I-8 was walking about the dayroom on 1 to 1 with staff.

II. Failure to reinforce the importance of and responsibility for patient attendance and participation in assigned treatment:

A. Observations and staff interview:

1. On 12/18/ 2012 at 2:00 PM the scheduled "Recreational Therapy Group" on the ICU Unit was observed to have 3 patients (I-1, I-4, I-7) of the total 13 patients on the unit at that time in the group. In the company of MHT #1, the surveyor asked to see what some of the other patients who were not attending their scheduled group were doing:
Patient 1-8 was in his/her room on 1:1 observation. The MHT #1 said: "[S/he] is resting. [S/he] needs it. [S/he] gets agitated. [S/he] has been here a couple of days."
Patient I-12 was in bed, as had been noted in the morning. When asked why, MHT #1 said "[S/he] is unsteady. We don't want [him/her] to fall."
Patient I-13 was also found in bed. MHT#1 explained "That is just "X" (referring to Patient I-13) and if "X" has a bad day, [s/he] will lay in bed all day."
Patient I-6 was found in bed. MHT #1explained "[S/he] didn't get any cigarettes, so [s/he] refuses to go to group."
Patient I-2 was found in bed. MHT #1 explained "[s/he's] probably just tired."

B. Staff Interviews and Record Review:

1. On 12/18/2012 at 2:45 PM, the surveyors met with the Clinical Director and the Director of Nursing (DON). The focus was on whether patients attend their assigned therapy groups and, if not, were their Master Treatment Plans (MTPs) revised. Two charts were chosen at random, in order to review documentation, as well as compare to ward observations of patients and staff interviews about patient participation.
Patient I-2's attendance at assigned groups for Dec. 11, 12, 13, 14, 15, 16, 17 was reviewed. Patient I-2 had attended 2 of the 14 groups available during that time frame. The MTP had been initiated on 12/07/2012 and reviewed by the treatment team on 12/14/2012. Both the Clinical Director and the DON acknowledged that no revision to the MTP had occurred that reflected the failure to involve Patient I-2 in the selected group interventions.

Patient I-13's attendance for group therapy was reviewed for the period Dec. 1, 2, 3, 4, 5, 6, and 7. Patient I-13 was found to have attended only 1 of the 14 available groups during that period. The MTP, the MTP Review dated 12/10/2012, and the MTP Review dated 12/17/2012, were examined. The MTP and its reviews failed to disclose any changes to reflect the lack of involvement of the patient in the therapeutic interventions (i.e. group therapies) selected. Both staff members agreed with this finding.

2. In interview with the facility's QI/UR manager on 12/17/2012 at 4:40 PM a review of Patient I-8's MTP dated 12/13/2012 was done. It was confirmed by the QI/UR manager that there were no interventions for Patient I-8's agitated behaviors, given the patient's inability to attend scheduled therapy groups because of the agitation.

3. In interview with the ICU QI/UR manager on 12/17/2012 at 4:40 PM she was questioned about the lack of treatment interventions for patient I-8's agitated behavior and/or group refusals. She stated that management of the milieu was a joint responsibility between Nursing and Social Work: the Social Work staff was responsible for conducting groups and family sessions, and discharge planning. She could not identify who was responsible for designing treatment interventions when patients refused to attend assigned groups.

4. In interview with the group leader SW #1 on 12/17/2012 at noon SW #1 said that patients are asked to go to the scheduled groups, but they refuse.

5. In interview with RN#3 on 12/18/2012 at approximately 2:00 PM, when asked "how do you get patients to group?" she responded "We ask them to attend, but we were told that we can't force them to attend." When asked "what is the alternative for the patients?" she responded "They can do what they want."

III. Policy Review

On 12/19/2012 at approximately 10:00 AM the Director of QI/UR provided the surveyors with the facility policy for revision to MTPs when selected treatment interventions are unsuccessful. The facility's policy titled "Plan for Provision of Care," date issued 2/29/12, states in Section 8 "Evaluation": "This plan for the provision of patient care is reviewed and revised as necessary." In subsection 8.4 the policy details patient care specifically as "Changes in patient care needs/community needs..." Thus, the staff on the facility's ICU failed to follow hospital policy in making revisions to interventions when those interventions were seen to be ineffective.

Based on observations, medical record and hospital policy review, and staff interviews it was determined that the Clinical Director failed to:

I. Ensure that patients on the ICU who were not attending their assigned treatment group theapy interventions were provided alternative interventions.

Findings include:

A. On 12/18/12, two patient records (I-2 and I-13) were randomly chosen for review with the Clinical Director and the Director of Nursing. Patient I-2's attendance at assigned groups for Dec. 11, 12, 13, 14, 15, 16, 17 was reviewed. Patient I-2 had attended 2 of the 14 groups available during that time frame. The MTP had been initiated on 12/07/2012 and reviewed by the treatment team on 12/14/2012. Both the Clinical Director and the Director of Nursing acknowledged that no revision to the MTP had occurred that reflected the failure to involve Patient I-2 in the selected group interventions.

Patient I-13's attendance for group therapy was reviewed for the period Dec. 1, 2, 3, 4, 5, 6, and 7. Patient I-13 was found to have attended only 1 of the 14 available groups during that period. The MTP, the MTP Review dated 12/10/2012, and the MTP Review dated 12/17/2012 were examined. The MTP and its reviews failed to disclose any changes to reflect the lack of success for the therapeutic interventions (i.e. group therapies) selected.

B. Patients were observed sleeping or otherwise avoiding group attendance at multiple times during the survey process. Refer to B125 Parts I & II for details of these observations.

II. Ensure that treatment staff on the ICU followed hospital policy that requires changes be made to the Treatment Plan when selected interventions are unsuccessful.

Findings include:

A. The facility's policy titled "Plan for Provision of Care," date issued 2/29/12, states in Section 8 "Evaluation": "This plan for the provision of patient care is reviewed and revised as necessary."

B. Staff interviews revealed that the staff members were aware patients were not participating, and that treatment plans were not revised in light of those patient failures. See B125 Part II for details. Thus, the staff on the facility's ICU failed to follow hospital policy in making revisions to interventions when those interventions were seen to be ineffective.
These failures can result in patients not participating in available treatment alternatives and can result in a longer than necessary hospitalization.

Based on record review, observation, and interviews, it was determined that the Director of Nursing failed to monitor the quality and appropriate of services and treatment provided by nursing staff. Specifically, the Director of Nursing failed to:

I. Ensure that patients on the Intensive Care Unit participated in assigned treatment, and that, when patients did not participate, nurses documented the reasons and planned ways to effectively involve patients in alternative treatment to that prescribed.

II. Ensure that the Master Treatment Plans (MTPs) of patients on the ICU were modified to include specific nursing intervention/modalities when patients demonstrated that they did not/could not comply with the modalities initially assigned on the MTP. In the case of active sample patient I-8, the patient was demonstrating agitation which precluded his/her attendance at scheduled group therapy, but the plan was not modified. For other patients on the unit, observation revealed that the majority of them did not attend scheduled group therapy modalities; random selection of two (I-2, I-13) of ten records of these patients revealed that the patients did not attend group therapy, yet scheduled MTP reviews by staff did not note this as a problem, and did not include alternate modalities to engage the patients in active treatment.

These deficiencies can result in lack of accountability and fragmented nursing care for patients.

Findings include:


I. Lack of patient participation in therapeutic activity


A. In interview with RN#3 on 12/18/2012 at approximately 2:00 PM, when asked "how do you get patients to group?" she responded "We ask them to attend, but we were told that we can't force them to attend." When asked "what is the alternative for the patients?" she responded "They can do what they want."

B. On 12/17/2012 at 11:40 AM, accompanied by RN#1, it was observed that 9 of 13 patients were not in the scheduled group: patients I-8, I-9, I-10, I-11 and I-13 were in bed, and patients I-3, I-4, I-5 and I-7 were either sitting in the day room or in bed sleeping instead of attending the scheduled group therapy.

C. On 12/18/2012 the census was 11 patients. At 11:45 AM there were 3 patients (I-1, I-7, I-12) in the scheduled "Process Therapy Group." In the company of the DON the other 8 absent patients were located: Patient I-1, Patient I-2, Patient I-12 and Patient I-13 were each in their beds; Patient I-11 was walking in the hallway; Patients I-4 and I-3 were in the day room; I-8 was pacing the dayroom observed by staff.

II. Lack of revision of nursing intervention(s) on the Master Treatment Plans when patients did not/could not attend group therapy.


A. In interview with the facility's QI/UR manager on 12/17/2012 at 4:40 PM a review of Patient I-8's MTP dated 12/14/2012 was done. The manager confirmed that there were no interventions on the plan for Patient I-8's agitated behaviors, other than the prescription of scheduled therapy groups, which the patient was too agitated to be able to attend.

B. On 12/18/2012 at 2:45 PM, the surveyors met with the Clinical Director and the DON. The focus was on whether patients attended their assigned therapy groups and, if not, were their Master Treatment Plans (MTPs) revised. Two charts were randomly chosen for review:

1. Patient I-2's attendance at assigned groups for Dec.11, 12, 13, 14, 15, 16, 17 was reviewed. Patient I-2 had attended 2 of the 14 groups available during that time frame. The MTP had been initiated on 12/07/2012 and reviewed by the treatment team on 12/14/2012. Both the Clinical Director and the DON acknowledged that no revision to the MTP had occurred that reflected the failure to involve Patient I-2 in the selected group interventions.

2. Patient I-13's attendance for group therapy was reviewed for the period Dec.1, 2, 3, 4, 5, 6, and 7. Patient I-13 was found to have attended only 1 of the 14 available groups during that period. The MTP, the MTP Review dated 12/10/2012, and the MTP Review dated 12/17/2012 were examined. The MTP and its reviews failed to disclose any changes to reflect the lack of for the patient's involvement with the therapeutic interventions (i.e. group therapies) selected. Both the Clinical Director and the DON agreed with this finding.