HospitalInspections.org

Based on observations and interview the hospital failed to maintain a safe environment as evidenced by: 1) failing to ensure chemicals on the Children/Adolescent's unit were stored in a closet that was locked at all times; 2) allowing a broken, hard plastic lid to a linen cart with jagged, hard, pointed, sharp edges to be accessible to the patients utilizing the dayroom of the Children/Adolescent's Unit; 3) failing to maintain window frames and jams resulting in flaking and peeling paint; 4) failing to inspect air-conditioning vents resulting in paper and rags being inserted preventing air flow. Findings:

1) Failing to ensure chemicals on the Children/Adolescent's unit stored in a secured area were locked at all times:
Environmental observations were made on 02/22/12 at 10:50 a.m. with RN S28 Nurse Manager of the Child/Adolescent Unit, S33 Maintenance, and RN S34 Risk Manager. While on the Children/Adolescent Unit, a room labeled "Environmental Services" that contained eye wash equipment and chemicals was found to be unlocked and unsupervised at the time. The following chemicals were found on the bottom shelf of an open cabinet in the room: 2 containers of urine odor eliminator, 1 can of oven cleaner, 3 spray cans of insect killer, 1 gallon of disinfectant, 1 gallon of Febreze, and 1 gallon of floor cleaner.

On 02/22/12 the total census on the children's/adolescent unit was 13. There were (1) 8 year old, (1)12 year old, (1) 13 year old, (2) 14 year olds, (3)15 year olds, (1) 16 year old, and (4) 17 year olds residing on the children/adolescent unit.

An interview was conducted with S33 Maintenance on 02/22/12 at 10:50 a.m. He reported the door was to be locked at all times since there were chemicals in the room.

2) Allowing a broken hard plastic lid to a linen cart with jagged, hard, pointed, sharp edges to be accessible to the patients utilizing the dayroom of the Children/Adolescent's Unit:
Observation on 02/22/12 at 10:50 a.m. of the common area/dayroom revealed a dirty linen cart with a hard white plastic lid. Further observation revealed the lid had numerous pieces broken leaving the remainder of the lid with jagged, hard, pointed sharp edges. The finding was confirmed with S33 Maintenance.

3) Failing to maintain window frames and jams resulting in flaking and peeling paint:
Observation on 02/22/12 at at 11:00am of Room "a" revealed the window sill was rusted and flaking. Further review revealed the paint surrounding the window was bubbled and in some places was also flaking. The window pane had a deep approximately seven inch scratch which was almost completely through the thickness of the window pane.

In a face-to-face interview on 02/22/12 at 11:00am, S33 Maintenance Director indicated he performed monthly inspections of the environment; however windows are not part of the check.

4) Failing to inspect air-conditioning vents resulting in paper and rags being inserted preventing air flow:
On 02/22/12 at 11:40 a.m., observation on the Dual Diagnoses Unit revealed paper, cardboard and/or washcloths had been placed behind the plastic vent covers of the air conditioner unit preventing the flow of air. S33 Maintenance verified that patients slide things under the vent cover to block the air.

Based on record review and interview the hospital failed to ensure adverse patient events were documented and their cause analyzed for 3 of 24 sampled patients (#3, #6, #14). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself". RN notified Psychiatrist S8 & pt was placed on SVC (strict visual contact). (1) Staff provided support, guidance, & encouragement. (o) Pt not compliant (with) unit rules & structure. Pt needs redirection from staff. (P) continue to monitor & follow tx (treatment) plan". Further review revealed no documented evidence of an assessment by the RN of the patient's change in condition that included a suicide attempt. Review of the "Patient Monitor Record" documented by PC S31 and dated 11/10/11 revealed Patient #3 was asleep in Module C (children's unit) at 11:00pm.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed in relation to Patient #3's suicide attempt and suicide threat.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN on 11/10/11 when she notified Psychiatrist S8 of the above report from PC S31. S28 further indicated an incident report should have been completed by the RN. S28 further indicated PC S31 documented her note for the entire shift at 11:00pm, and there was not the specific time that the event with Patient #3 had occurred, which resulted in the observation record and the progress notes information not matching.

Review of Patient #3's "Progress Notes" dated 11/12/11 at 10:50 (no documented evidence whether it was am or pm) revealed documentation by PC S42 of "...He began attention seeking and pulling a towel around his neck. He started cursing and disrespecting staff...". Further review revealed no documented evidence that this was reported to the RN, and there was no documented evidence of a RN's assessment of Patient #3's suicide attempt. Review of Patient #3's "Patient Monitor Record" dated 11/12/11 revealed from 10:45am through 11:00am, Patient #3 was cooperative in Module C, and from 10:45pm through 11:00pm he was sleeping in the quiet room.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN, and an incident report was required to be completed when patients made suicide attempts or threats.

In a face-to-face interview on 02/27/12 at 11:50am, RN Manager of the Child/Adolescent Unit S28 indicated the RN should document an assessment of the patient behaviors that warranted the need for prn medication.

In a face-to-face interview on 02/27/12 at 2:20pm, RN Risk Manager S34 indicated incident reports were to be reviewed by the supervisor and signed on the day the report was written, and she (S34) was to review and sign the report by the following day.

Patient #6
Patient #6 was an 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the Progress Notes dated 12/02/11 at 9:20 p.m. revealed, "Pt (patient) became agitated, banging on walls, cursing, and tying his sheets around his neck. Pt made verbal threats to kill staff".

Review of the Incident and Accident reports for December 2011 revealed no documented evidence of an incident and accident report related to the patient attempting to tie sheets around his neck.

An interview was conducted with S 28 Nurse Manager on 02/27/12 at 11:10 a.m. She reported that an incident report should had been filled out related to the patient attempting to tie a sheet around his neck on the unit.

Patient #14
Review of Patient #14's medical record revealed he was admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 01/29/12 revealed an entry at 2:30pm by PC S36 of "...being physically aggressive punching a male child on the face over a movie. Pt was stopped by a female PC & was put in his room by other nursing staff who came to assist. Doctor was called by nurse & she told PCs that if pt stays in his room & he is able to calm himself down he will be okay no shot but a Vistaril by mouth... pt was put on early bedtime & no privileges. Monitor pt behavior encourage pt to follow his treatment plan...". Further review revealed no documented evidence of an assessment of Patient #14 by a RN and the report of the RN's phone call to the physician.

Review of the hospital's incident report log revealed no documented evidence that an incident report was completed related to Patient #14 striking another patient in the face.

In a face-to-face interview on 02/27/12 at 11:05am, PC S36 indicated she reported that Patient #14 had struck another peer in the face on 01/29/12 to the charge nurse, but she doesn't remember which nurse she told. S36 further indicated that she didn't know if an incident report had been completed at the time of the incident.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 02/02/12 revealed a shift entry by PC S20 of "...appeared to have a limited affect. He could not participate in the activities & group because his behavior was out of control. He stated that he will do what he want. x 2 in the quiet room for his inappropriate behaviors...". Further review revealed no documented evidence that a RN assessed Patient #14's behaviors when he was "out of control" that warranted him to be placed in the quiet room twice by PC S20.

In a face-to-face interview on 02/27/12 at 9:02am, PC S20 indicated she placed a child in the seclusion room and left the door open when she documents that they are in the quiet room. S20 further indicated she kept the patient from exiting the room until they've "done their little time out". S20 further indicated she decides when the patient can come out of the seclusion/quiet room. When asked if she's familiar with the seclusion policy, S20 indicated that she was and reviewed it every 2 to 3 weeks. After being told that the hospital policy considered it to be seclusion when a patient was not allowed to leave a room, S20 reconfirmed that she kept patients from leaving the seclusion room when she placed them there for time-out until she determined that the patient could leave.

Review of Patient #14's "Reassessment/Progress Note dated 02/15/12 revealed documentation written across the front of the page with no documented evidence of the date, time, and name and title of the person who made the notation. Further review revealed the documentation included "Vistaril 25 mg p.o. (by mouth) at 4PM - agitated angry hostile threatening". Review of the PRN MAR revealed Vistaril 25 mg was given by mouth on 02/15/12 at 10:00pm. Review of the "Multidisciplinary Progress Notes" dated 02/15/12 revealed no documented evidence of an assessment by the RN of the behaviors exhibited by Patient #14 that warranted the need for prn medication at 4:00pm and 10:00pm.

In a face-to-face interview on 02/27/12 at 11:15am with RN Manager of the Child/Adolescent Unit S28 and RN Manager S11 present, S28 indicated an incident report should have been completed if the other patient was injured (relating to the above incident of 01/29/12). S11 indicated an incident report needed to be completed at the time even if the other patient was not injured. S28 indicated the RN should have performed and documented an assessment of Patient #14's behaviors. RN Manager S11 confirmed that an incident report had not been completed when Patient #14 struck another patient in the face on 01/29/12.

Review of the hospital policy titled "Healthcare Peer Review (HPR) Occurrence Reporting System", reviewed 08/11, revised 05/05, and contained in the policy manual submitted by Administrator S1 as current, revealed, in part, "...Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. ...Serious Injuries/Events constitute any of the following outcomes as a result of healthcare intervention but may not be limited to this list: ...Suicidal gestures or attempt, Injury/Physical harm to patients, staff or third parties... Violence...". Further review revealed the incident report was to be completed at the time of the event, signed by the individual preparing the report, reviewed by the charge nurse on duty at the time of the event for completeness and to assure the medical record documentation was appropriate and appropriate actions/interventions had been taken.

Based on record review and interview the hospital failed to enforce its bylaws. The medical staff did not implement its rules and regulations for suspension and disciplinary action of physicians who failed to complete medical records within 30 days after discharge. Findings:

Review of the Medical Staff Rules and Regulations revealed in part,"....On the thirtieth (30th) day after discharge, if the record is incomplete, the Medical Director, the Chief Executive officer, and the Chairman of the Medical Executive Committee will be notified to consider suspension of privileges or other appropriate disciplinary action. Suspension of clinical privileges will usually apply to future cases only. When privileges are suspended, the practitioner must complete all incomplete records before his/her privileges will be reinstated. A record is not complete until all material has been dictated, transcribed, and signed...".

Review of the Physician Delinquency rate for January 2012 revealed the total rate was 39% and the delinquent rate for the year 2011 was 42%.

Review of the Physician Delinquency rate per physician revealed:
S 8 MD had 6 charts over 30 days delinquent, 1 chart over 60 days delinquent, and 1 chart over 90 days delinquent.
S 19 MD had 7 charts over 30 days delinquent, 6 charts over 60 days delinquent, and 4 charts over 90 days delinquent.
S 40 MD had 2 charts over 30 days delinquent and 4 charts over 90 days delinquent.
S 41 MD had 1 chart over 30 days delinquent and 2 charts over 90 days delinquent.
S 39 MD had 1 chart over 30 days delinquent.
S 38 MD had 1 chart over 234 days delinquent.

An interview was conducted with S30 RHIA (Registered Health Information Administrator) on 02/24/12 at 9:25 a.m. She reported that the delinquency rate for medical records was 39% for January. She reported the system in place to notify the doctors of delinquent charts was to e-mail them once a week and "cc" S1 Administrator and S18 Medical Director. S30 stated she had been at the hospital about 4 years, and none of the physicians' privileges had been suspended for delinquent medical records.

An interview was conducted with S18 MD on 02/27/12 at 2 p.m. He stated he was the Medical Director of the hospital, and once a month in the Medical Executive Committee the delinquent rate per physician is presented to him. He further reported he speaks to the physicians and reminds them about their delinquent records. He also stated there was no disciplinary actions or suspension of privileges related to delinquent records, because he did not see the need for it.

Based on record review and interview, the hospital failed to ensure the short-term and long range goals included specific dates for expected achievement and were written as observable, measurable patient behaviors to be achieved for 5 of 24 sampled patients (#3, #4, #11, #13, #14). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Master Treatment Plan" dated 11/08/11 revealed his problems identified were mood lability with threats to harm others and oppositional and defiant behavior.

Review of the short-term goals for oppositional behavior revealed Patient #3 would identify 3 triggers to defiant/uncooperative behavior and identify 3 alternative behaviors to function appropriately with staff and peers. Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #3 was to "develop positive social behaviors and coping skills to manage uncomfortable feelings". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for mood lability revealed Patient #3 would identify 3 triggers to angry outbursts and identify 3 positive coping skills to manage angry feelings. Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #3 was to "develop positive coping skills to deal (with) feelings". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 with diagnoses of Psychoses, Major Depressive Disorder, and Suicidal Ideations (SI). Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/15/11 at 12:19 p.m. due to Patient #4 having violent behavior for the past 3 weeks. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Master Treatment Plan" dated 11/18/11 revealed his problems identified were mood liability with anger and suicidal ideations and family conflict.

Review of the short-term goals for family conflict revealed Patient #4 would "Identify 5 things at home that make him sad/mad, List 3-5 compromises to consider". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #4 was to "Complete family session". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for mood liability revealed Patient #4 would "Identify 5 things that make him mad/sad, Identify 5 people to call when upset, List 3 coping skills". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #4 was to "Stabilize mood/Deny SI (suicidal ideations)". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 with diagnoses of Major Depressive Disorder and Suicidal Ideations. The record revealed the patient was PEC'd on 12/30/11 at 9:15 a.m. for suicidal ideations. The patient was discharged from the facility on 01/03/12.

Review of Patient #11's "Master Treatment Plan" dated 01/02/12 revealed the patient's problems identified were mood liability with SI and family conflict.

Review of the short-term goals for family conflict revealed Patient #11 would "Identify 5 things at home that upset her, List 3-5 compromises to consider". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #11 was to "Complete family session". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for mood liability revealed Patient #11 would "Identify 5 things that make her sad/upset, Identify 5 people to call when upset, List 3 coping skills". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #11 was to "Stabilize mood/Deny SI". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood lability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others.

Review of the short-term goal for mood lability revealed Patient #13 would identify 5 things that make him upset by day 2 and identify 5 people to talk to when upset by day 3. Further review revealed no documented evidence whether Patient #3 had met these goals by day 2 and day 3 or whether the goals had to be revised. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #13 was to stabilize mood and deny suicidal and homicidal ideations. There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for behaviors resulting in danger to self or others revealed Patient #13 was to identify 3 triggers to his anger within 5 days of admit and identify 3 positive coping skills to use when feeling angry within 5 days of admit. Further review revealed the expected achievement date for the goals was 5 days after admit, and the treatment plan was developed on 02/17/12, 13 days after his admit date. Further review revealed the goals were not written as observable, measurable patient behaviors.

Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Master Treatment Plan" dated 01/29/12 revealed his problems identified were mood lability and ineffective coping.

Review of the short-term goal for mood lability revealed Patient #14 was to identify 5 triggers to angry outbursts by day 2 and identify 5 coping skills to use when angry by day 3. Further review revealed the expected achievement date for the goals was 2 and 3 days after admit, and the treatment plan was developed on 01/29/12, 4 days after his admit date. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #14 was to demonstrate a decrease in the number of outbursts 48 hours prior to discharge. There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goals for ineffective coping revealed Patient #14 was to identify 3 coping skills to assist with focus on progress in process group by day 2. Further review revealed the expected achievement date for the goals was 2 days after admit, and the treatment plan was developed on 01/29/12, 4 days after his admit date. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #14 was to learn 5 coping skills before discharge. There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/04/12 revealed the progress made since the last review of problem 1 (mood lability) was that Patient #14 was attacking his roommate. Further review revealed the short-term goal was for Patient #14 to work on anger management with staff. Further review revealed the goal was not written as observable, measurable patient behaviors, did not include an expected date of achievement, and there were no interventions documented. Further review revealed the progress made since the last review of problem 2 (ineffective coping) was that Patient #14 was trashing his room when he was not given his way. The short-term goal was that he would work on impulse control with the staff. Further review revealed the goal was not written as observable, measurable patient behaviors and did not include an expected date of achievement.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/11/12 revealed the progress made since the last review of problem 1 (mood lability) was that Patient #14 was arguing with peers and trying to intimidate peers. Further review revealed the short-term goal was for Patient #14 to decrease aggressiveness and argumentativeness. Further review revealed the goal was not written as observable, measurable patient behaviors, did not include an expected date of achievement, and there were no interventions documented. Further review revealed the progress made since the last review of problem 2 (ineffective coping) was that Patient #14 was oppositional and more focused on his peers' behavior than his own. The short-term goal was that Patient #14 would focus on his behavior and follow milieu and staff directions. Further review revealed the goal was not written as observable, measurable patient behaviors and did not include an expected date of achievement.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/18/12 revealed the progress made since the last review of problem 1 (mood lability) was that Patient #14 was demonstrating increased hyperactivity and had increased difficulty settling down for bedtime and his bath. The short-term goal was that Patient #14 would calm down and be ready for bed with no talking in 2 days. Further review revealed the goal was not written as observable, measurable patient behaviors.

In a face-to-face interview on 02/27/12 at 9:00am with Administrator S1, Director of Nursing S2 and Corporate Director Clinical Services S46 , neither S1, S2, nor S46 could offer an explanation for the patients' treatment plans not having specific dates for expected achievement of short-term and long range goals and for not being written as observable, measurable patient behaviors to be achieved.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...".

Based on record review and interview, the hospital failed to ensure the written treatment plan included the specific treatment interventions to be used for each patient for 5 of 24 sampled patients (#3, #4, #11, #13, #20). Findings:

Review of the hospital's "Problem Description" for "Mood Liability" revealed a blank for the patient's name, the problem number, the behavioral observations, and the long term goal. Further review revealed a column labeled "objective/short-term goal", a column labeled interventions/frequency, and a column labeled "staff responsible". Review of the "interventions/frequency" revealed the following pre-printed interventions: "(Identify main interventions used with individual patient during treatment.) (box to be checked) Individual MD (physician) sessions ___ per week. Activity Therapy (___/1 hr(hour)/daily) to develop techniques (box to be checked) journaling (box to be checked) art (box to be checked) exercise (box to be checked) music (box to be checked) other ___ to decrease target symptoms. (Box to be checked) Process group (___ x/1 hr/daily) to assist with (box to be checked) reorientation (box to be checked) grounding (box to be checked) redirection (box to be checked) other ___. (box to be checked) Milieu therapy daily to assist in obtaining increased levels within level system to learn (box to be checked) responsibility (box to be checked) motivation (box to be checked) other ___. (box to be checked) Evaluate patient daily for evidence of decreased: (box to be checked) racing thoughts (box to be checked) energy (box to be checked) impulsiveness, or increased: (box to be checked) sleep (box to be checked) appetite (box to be checked) concentration. Other:".

Review of the hospital's "Problem Description" for "Oppositional Behavior" revealed a blank for the patient's name, the problem number, the behavioral observations, and the long term goal. Further review revealed a column labeled "objective/short-term goal", a column labeled interventions/frequency, and a column labeled "staff responsible". Review of the "interventions/frequency" revealed the following pre-printed interventions: "(Identify main interventions used with individual patient during treatment.) (box to be checked) Individual MD sessions ___ x/week, focusing on ___ (box to be checked) Milieu therapy daily to assist in obtaining increased levels within level system to learn responsibility motivation. (box to be checked) Activity Therapy (___/1hr/weekly) to provide format for non-verbal expression of feelings and to aide in development of coping skills (box to be checked) journaling (box to be checked) exercise (box to be checked) affirmations (box to be checked) self talk (box to be checked) music/art (box to be checked) other ___ (box to be checked) Process group (___/1hr/weekly) to aide in identifying triggers to oppositional behavior. Other:".

Review of the hospital's "Problem Description" for "Family Conflict" revealed a blank for the patient's name, the problem number, the behavioral observations, and the long term goal. Further review revealed a column labeled "objective/short-term goal", a column labeled interventions/frequency, and a column labeled "staff responsible". Review of the "interventions/frequency" revealed the following pre-printed interventions: "(Identify main interventions with individual patient during treatment) (box to be checked) Evaluate patient's strengths, coping skills, and current support system on admission. (box to be checked) Process group (___/1hr/daily) to assist in identifying family issues (box to be checked) closed communication (box to be checked) substance abuse (box to be checked) abuse (specify) ___ (box to be checked) boundaries (box to be checked) other ___ (box to be checked) Activity Therapy (___/1hr/daily) to help find coping skills to address family conflicts (box to be checked) journaling) (box to be checked) exercise (box to be checked) walking away (box to be checked) music (box to be checked) art (box to be checked) other ___ (box to be checked) Family sessions (___/1hr/weekly) to open communication and process inconsistencies (box to be checked) limit setting (box to be checked) Clarification of roles (box to be checked) boundary setting (box to be checked) communication ties (box to be checked) other Other:".

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Master Treatment Plan" dated 11/08/11 revealed his problems identified were mood liability with threats to harm others and oppositional and defiant behavior. Review of the interventions and frequency to be used for "Mood Liability" and "Oppositional Behavior" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 with diagnoses of Psychoses, Major Depressive Disorder, and Suicidal Ideations (SI). Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/15/11 at 12:19 p.m. due to Patient #4 having violent behavior for the past 3 weeks. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Master Treatment Plan" dated 11/18/11 revealed his problems identified were mood liability with anger/suicidal ideations, and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 with diagnoses of Major Depressive Disorder and Suicidal Ideations. The record revealed the patient was PEC'd on 12/30/11 at 9:15 a.m. for suicidal ideations. The patient was discharged from the facility on 01/03/12.

Review of Patient #11's "Master Treatment Plan" dated 01/02/12 revealed the patient's problems identified were mood liability with SI (suicidal ideation) and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood liability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others. Review of the "interventions/frequency" to be used for "Mood Liability" and "Family Conflict" revealed a number was written in the blank for the frequency. Further review revealed there was no documented evidence that a box had been checked to designate which intervention was to be used and what the focus was to be.

Patient #20
Review of the medical record for Patient #20 revealed a 54 year old female admitted to the hospital on 10/29/11 under a formal voluntary admission for opiate dependency with a history of fibromyalgia.

Review of the Problem Description for abuse of opiates for Patient #20 revealed in the column for interventions and frequency the following: a check in the box indicating administer and monitor patient daily on effects of medications as ordered; however all boxes next to the medications were left blank.

Review of the Physician's Orders for Patient #20 revealed the following medications were ordered: 10/29/11 at 5:00pm Zanaflex 8mg po (by mouth) Q-4 (every four) hours prn (as needed) for muscle spasms, muscle or joint aches, Subutex 2mg SL (sublingual) q2H (every two hours) prn for s/s (signs and symptoms) of opiate withdrawal, Sandostatin 100 mcg Sub cut. (subcutaneous) Q-4 hours prn for nausea, vomiting or diarrhea, Phenergan 50mg po Q-6 hours prn nausea and vomiting and Catapres 0.1mg po q-2 hours prn pulse over 90 s/s of opiate withdrawal.

Review of the MAR (Medication Admission Record) revealed Patient #20 received the following medications:
Subutex 2mg Q 2 hours - 10/29/11 at 6:00pm, 8:00pm, 10:00pm; 10/30/11 at 9:25am and 5:45pm
Zanaflex 8mg po Q-4 hours - 11/01/11 at 9:15am and 10:15pm
Catapres 0.1mg po q-2 hours - 11/01/11 7:15am and 10:25am
Further review of the medical record revealed no documented evidence Patient #20 was monitored for the effects of the drugs.

In a face-to-face interview on 02/27/12 at 9:00am with Administrator S1, Director of Nursing S2 and Corporate Director Clinical Services S46 , neither S1, S2, nor S46 could offer an explanation for the patients' treatment plans not having the specific treatment interventions selected.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...".

Based on record review and interview the hospital failed to ensure the written treatment plan included the responsibilities of each member of the treatment team for 5 of 24 sampled patients (#3, #4, #11, #13, #14). Findings:

Review of the pre-printed forms used by the hospital to identify problems revealed the following: Top section of the page- Name of patient; Problem #; Problem (pre-printed diagnosis i.e. Depression); Behavioral Observations; and Long Term Goal. The rest of the page is divided into three columns: Column 1 for Short-Term Goals; Column 2 pre-printed interventions; and Column 3 the staff responsible.

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Master Treatment Plan" dated 11/08/11 revealed his problems identified were mood lability with threats to harm others and oppositional and defiant behavior. Review of the interventions and frequency to be used for "Mood Lability" and "Oppositional Behavior" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number. Further review revealed the column for "staff responsible" had the name of the psychiatrist, a registered nurse, a licensed medical social worker, and a psychiatric counselor with no documented evidence for which intervention each staff member was responsible.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 with diagnoses of Psychoses, Major Depressive Disorder, and Suicidal Ideations (SI). Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/15/11 at 12:19 p.m. due to Patient #4 having violent behavior for the past 3 weeks. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Master Treatment Plan" dated 11/18/11 revealed his problems identified were mood liability with anger/suicidal ideations, and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number. Further review revealed the column for "staff responsible" had the name of the psychiatrist, a registered nurse, a licensed medical social worker, and a psychiatric counselor with no documented evidence for which intervention each staff member was responsible.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 with diagnoses of Major Depressive Disorder and Suicidal Ideations. The record revealed the patient was PEC'd on 12/30/11 at 9:15 a.m. for suicidal ideations. The patient was discharged from the facility on 01/03/12.

Review of Patient #11's "Master Treatment Plan" dated 01/02/12 revealed the patient's problems identified were mood liability with SI, and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number. Further review revealed the column for "staff responsible" had the name of the psychiatrist, a registered nurse, a licensed medical social worker, and a psychiatric counselor with no documented evidence for which intervention each staff member was responsible.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood lability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others. Review of the "interventions/frequency" to be used for "Mood Lability" and "Family Conflict" revealed a number was written in the blank for the frequency. Further review revealed there was no documented evidence that a box had been checked to designate which intervention was to be used and what the focus was to be. Further review revealed the name of the psychiatrist, the social worker, and "staff" was listed under "staff responsible". There was no documented evidence of a registered nurse named as staff who would be responsible for Patient #13's treatment plan. Further review revealed there was no documented evidence for which intervention each staff member was responsible.

Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Master Treatment Plan" dated 01/29/12 revealed his problems identified were mood lability and ineffective coping. Review of the "Problem Description" for mood lability and ineffective coping revealed there was no documented evidence for which intervention each staff member was responsible.

In a face-to-face interview on 02/27/12 at 9:00am with Administrator S1, Director of Nursing S2 and Corporate Director Clinical Services S46 , neither S1, S2, nor S46 could offer an explanation for the patients' treatment plans not including the responsibilities of each member of the treatment team.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...".

Based on record review and interview the hospital failed to ensure the patient's problems/needs, interventions, progress, and responses to treatment were assessed and documented by the nurse as evidenced by allowing, via policy and procedure, the delegation to the Psychiatric Counselor (Mental Health Technician) the assessment and documentation of the appearance of the patient, order changes, reasons for changes, reactions to changes, progress toward or away from treatment plan, and the patient's general mood and reactions for 9 of 24 sampled medical records (#3, #5, #8, #10, #14, #15, #19, #20, #24). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of the Reassessment/Progress Note for Patient #3 dated 11/11/11, 11/13/11, and 11/15/11 revealed no documented evidence the patient's progress was assessed by the registered nurse.

Patient #5
Review of Patient #5's "Psychiatric Admission Summary" revealed a 16 year old female admitted to the hospital on 11/23/11 under a PEC (Physician's Emergency Certificate) for suicidal thoughts and behavioral problems at home Further review of the medical record revealed the diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems and Cannabis Abuse.

Review of the Reassessment/Progress Note for Patient #5 dated 11/24/11, 11/25/11, 11/26/11, 11/27/11 and 11/28/11 revealed no documented evidence the patient's progress was assessed by the registered nurse.

Patient #8
Review of Patient #8's medical record revealed a 13 year old male admitted under a CEC (Coroner's Emergency Certificate) on 12/13/11 for uncontrollable anger. Further review revealed Patient #8 pulled a knife on his mother and became violent with property.

Review of the Reassessment/Progress Note for Patient #8 dated 12/13/11 3p-11p shift, 12/15/11, and 12/17/11 revealed no documented evidence a progress note had been written by the registered nurse.

Patient #10
Review of Patient #10's medical record revealed a 47 year old female admitted under a formal voluntary admit on 12/19/11 for sexual trauma. Further review revealed Patient #10 was placed under MVC/CO (Modified Visual Contact/Close Contact) per physician's orders.

Review of the Reassessment/Progress Note for Patient #10 dated 12/20/11, 12/21/11 3p-11p shift, 12/22/11 7a-3p and 3p-11p shifts, 12/24/11 7a-3p shift, 12/25/11, 12/26/11, 12/28/11 3p-11p and 11p-7a shifts, 12/29/11 7a-3p shift, 12/20/11 7a-3p and 30-11p shifts, and 11/28/11 revealed no documented evidence a progress note had been written by the registered nurse.

Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of the Reassessment/Progress Note for Patient #14 dated 02/08/12, 02/12/12, 02/14/12, and 02/16/12 revealed no documented evidence a progress note had been written by the registered nurse.

Patient #15
Review of Patient #15's medical record revealed a 16 year old male admitted to the hospital on 01/16/12 under a PEC (Physician's Emergency Certificate) for suicidal ideation and wanting to burn himself with a lighter.

Review of the Reassessment/Progress Note for Patient #15 dated 01/21/12, 01/22/12, 01/23/12 01/26/12 7a-3p shift, 01/29/12 3p-11p shift, 01/30/12 7a-3p and 11p-7a shifts, 01/31/12, 02/01/12 3p-11p and 11-7a, 02/09/12, 02/11/12 3p-11p shift, 02/13/12 11p-7a shift, 02/15/12 3p-11p and 11p-7a shift, 02/16/12 3p-11p shift, 02/17/12 11p-7a, 02/17/12 3p-11p, 02/18/12, 02/19/12 11p-7a and 3p-11p, 02/20/12 3p-11p, 02/21/11 7a-3p and 3p-11p, and 02/22/12 7a-3p revealed no documented evidence a progress note had been written by the registered nurse.

Patient #19
Review of Patient #19's medical record revealed a 26 year old female admitted to the hospital on 02/15/12 under a formal voluntary admission for opiate and benzo dependency.

Review of the Reassessment/Progress Note for Patient #19 dated 02/17/11, 02/18/12, 02/19/12 3p-11p shift, 02/20/12 7a-3p shift, 02/22/12 7a-3p and 3p-11p shifts revealed no documented evidence a progress note had been written by the registered nurse.

Patient #20
Review of the Patient #20's medical record revealed a 54 year old female admitted under a formal voluntary admission to the hospital on 10/29/11 for opiate dependency and withdrawal.

Review of the Reassessment/Progress Note for Patient #20 dated 10/31/11 7a-3p shift, 11/01/11 7a-3p shift, 11/03/11 3p-11p and 11p-7a shifts revealed no documented evidence a progress note had been written by the registered nurse.

Patient #24
Review of Patient #24's medical record revealed a 34 year old female admitted to the hospital on 09/05/11 under a PEC (Physician's Emergency Certificate) for positive paranoid thoughts and major depression.

Review of the Reassessment/Progress Note for Patient #24 dated 09/06/11 3p-11p shift and 09/09/11 11p-7a shift revealed no documented evidence a progress note had been written by the registered nurse.

In a face-to-face interview on 02/24/12 at 1:30pm, RN S2 DON (Director of Nursing) verified psychiatric counselors are allowed by the hospital to document in the patient's progress notes. Further she was not aware of any regulations requiring the nurse to document the progress of the patient. After review of several of the cited medical records, S2 verified in some cases the only documentation by the RN was the Patient re-assessment performed once every 24 hours.

Review of the policy titled "Patient Progress Notes" last reviewed in 2011 and submitted as the one currently in use revealed...."Procedure: C. Each patient must be charted on each shift. Charting progress notes is the responsibility of the staff nurses and psychiatric councilors on the day and evening shifts and on the night shift. Patient progress notes should be documented in the BIOP (Behavior-Intervention-Outcome-Plan) format. The following should be included in the patient progress notes: 1. Appearance of patient when staff arrives on program, including status regimen (i.e., SVC [Strict Visual Contact], full restraints, on pass, etc). 2. Any order changes, the reason for the change, and the patient's reaction to the change. 3. Techniques used by staff to accomplish goals on treatment plan. 4. Statement of progress toward or away from treatment plan goals. 5. Patient's behavior or general topic of verbalization in group psychotherapy. 6. Patient's general mood and reactions. 7. Any minor or major happenings during the shift, either to the patient or in the milieu that affects the patient's therapy. 8. At least once per shift on day and evening shift, a BIOP note should be charted. Note should address at least one or more treatment plan problems".

Based on record review and interview, the hospital failed to ensure each patient's progress notes contained recommendations for revisions in the treatment plan. Patients' treatment plans were not revised when there was a change in the patient's condition for 3 of 24 sampled patients (#3, #6, #13). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself".

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence his treatment was updated with interventions and goals for a suicide attempt and threat that occurred on 11/10/11.

In a face-to-face interview on 02/27/12 at 11:50am, RN S28 indicated Patient #3's treatment plan should have been updated when he attempted suicide by wrapping a sheet around his neck.

Patient #6
Patient #6 was a 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the Progress Notes dated 12/2/12 at 9:20 p.m. revealed, "Pt (patient) became agitated, banging on walls, cursing, and tying his sheets around his neck. Pt made verbal threats to kill staff."

Review of the Master Treatment Plan for Patient #6 revealed his Diagnoses are as follows:
Axis I: Depressive d/o(disorder) NOS (nonspecific) ADHD (Attention Deficit Hyperactivity Disorder), Combined type, r/o (rule out) Psychosis, NOS Disruptive Behavior d/o, NOS

His problems are listed as mood lability and family conflict. Problem #1 is listed as mood lability. His short term goals are: identify 3 challenges to deal with when he hears voices telling him to things within 5 days of admit. His other short term goal is to identify 5 coping skills to use when hearing the voices within 5 days of admit. Problem #2 is listed as family conflict. His short term goals are to identify 2 major problems he is having at home within 5 days of admit and to identify 2 ways he can help to increase communication within 5 days of admit.

With review of the Master Treatment Plan and the 2 problems identified, there was no documentation of the episode of the patient tying sheets around his neck on 12/2/11 while in the hospital. The episode was not addressed or included in the treatment plan.

An interview was conducted with S 28 RN manager and S 11 RN Manager on 02/27/12 at 11:15 a.m. They stated the episode of the patient tying his sheets around his neck was not addressed in the Treatment Plan and should have been addressed. The patient was discharged on 12/8/11 from the hospital.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood lability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others.

Review of Patient #13's "Multidisciplinary Notes" dated 02/21/12 at 10:00pm revealed RN S32 documented "redirected many times for pulling his pants below his buttocks & (and) showing his underwear...".

Observation on 02/23/12 at 10:35am revealed Patient #13 attended a group session led by MSW (medical social worker) S26. Observation revealed Patient #13 continued to move from chair to chair in the room and pulled his pants leg up to show his underwear. During the observation S26 had to instruct Patient #13 to put his pants leg down.

Review of Patient #13's medical record revealed he was placed in seclusion on 02/15/12 at 4:15pm due to him jumping on tables, running, throwing toys at staff, attempting to scratch and bite staff, kicking, and head-butting. Further review revealed Patient #13 was placed in seclusion on 02/21/12 at 8:45pm due to being extremely oppositional and defiant and refusing all redirections. Further review revealed he was placed in seclusion on 02/23/12 at 3:15pm due to screaming and kicking, biting, punching, and scratching staff.

Review of Patient #13's "Master Treatment Plan" revealed no documented evidence his plan was updated to include sexually inappropriate behaviors and the continued need for seclusion. Further review revealed his "Mood Lability", "Behaviors resulting in danger to self or others", and "Family Conflict short term goals were to be accomplished by day 2, day 3, and day 5 of treatment. There was no documented evidence whether the goals had been accomplished or whether they had been revised by 39 days after admit.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 confirmed that Patient #13's treatment plan was not revised to include sexually inappropriate behavior. S28 indicated the behavior wasn't present when the care plan was developed. In the same interview, RN Manager S11 indicated the patient's care plan can be revised as needed and did not have to be done at the weekly treatment team meeting.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...Procedure: 7. The master treatment plan shall be updated frequently as clinically indicated, and at least as often as every 7 days.....".

Based on record review and staff interview, the facility failed to ensure that each patient who was discharged had a discharge summary that was accurate and dictated within 30 days of discharge for 2 (#4, #9) of 14 sampled discharged records reviewed out of a total sample of 24. Findings:

Review of the policy and procedure titled, "Analyzing Records-Discharge Summary", with no policy number, page 1 of 2, last revised date of 10/11, presented as the hospital's current policy, revealed the following:
"Policy: Verifies that patient record contains all pertinent information and if complete.
Procedure:
Responsibility: Attending Physician
Action: Dictates discharge summary within 30 days of patient's discharge.
B. Clinical Resume - The discharge summary includes a clinical resume that summarizes the following: Initial Assessment/Diagnosis, Clinical course of hospitalization, Final Assessment/Diagnosis, Condition on Discharge, Prognosis, Aftercare Planning/Recommendations/ Medications, Living arrangements, Diet, Level of physical activity".

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 as a PEC (Physician Emergency Commitment) for violent behavior. The record revealed the patient was discharged to home on 11/18/11. Review of the Psychiatric Evaluation revealed the patient's diagnosis was Major Depressive Disorder with Anxious Features.

Review of the record revealed there was no documented evidence of a discharge summary.

On 02/27/12 at 12:20 p.m., a face to face interview was conducted with the Director of Nursing, S2RN. After reviewing the patient's record, she verified there was no discharge summary on the record. S2 verified that the patient was discharged on 11/18/11 and the discharge summary should be on the record by this date (101 days after the patient's discharge). S2 verified the hospital's policy of dictating the discharge summary within 30 days of discharge.

Patient #9
Review of the patient's clinical record revealed the patient was a 31 year old female admitted to the facility on 12/19/11 as a formal voluntary admission for Bi-Polar Depression (Per Physician's Admission Orders). Review of the record revealed that the patient was discharged from the inpatient facility on 12/23/11.

Review of the Psychiatric Discharge Summary, dictated on 02/22/12 at 12:00 p.m. (66 days after discharge) revealed the following:
"Date of Admission: 01/03/12
Date of Discharge: 01/09/12
History of Present Illness: The patient is a 31-year old Caucasian female with bipolar disorder, on lithium, who was PEC'd to River Oaks Hospital on 01/01/12 secondary to depressed mood with suicidal ideation and feelings of hopelessness and helplessness....."

Further review of the record revealed no documented evidence of a discharge summary that addressed the patient's inpatient stay. There was also no documented evidence of a PEC.

On 12/27/12 at 12:00 p.m., a face to face interview was conducted with the Director of Nursing, S2RN. After reviewing the patient's record, she verified the discharge summary had not been dictated within 30 days of the patient's discharge. S2RN verified that there was no evidence of a PEC on the record and stated that the record indicated that the patient was a voluntary admission. She verified the discharge summary did not reflect the patient's inpatient admission. S2RN verified that discharge summary on the patient's record was not an accurate recapitulation of the patient's hospitalization.