HospitalInspections.org

Based on observation, record review and interview, the facility's staff failed to document Time Out was done prior to initiation of Electroconvulsive therapy in 1 of 2 patients observed for ECT. Patient #7

Findings:

Review of the Facility's current Policy and Procedure on Electroconvulsive therapy Enforcement and Penalties, E 101, last revised 12/2014 directs staff as follows: "Pre _ Procedure Universal Protocol: A time out is conducted immediately prior to introduction of anesthesia. The following steps will occur: Time out is initiated by a designated member of the team, involves all members of the procedure team, Involves interactive verbal communication between team. Time out addresses the following: Correct patient identity, accurate procedure consent form; safety precautions based on patient history or medication."

Patient #7
Observation on 12/10/2014 at 9.22 a.m revealed Anesthesiologist #77 was observed in the Electroconvulsive therapy suite conducting ECT on patient #7.

Review of the patient's ECT notes revealed patient (#7) had Electroconvulsive Therapy on 12/08/2014. Review of the record revealed no indication that time out was conducted prior to initiation of the procedure. The section on the ECT Verbal time out was blank.

On 12/10/2014 at 10.05 a.m the Surveyor reviewed the patient's clinical record with the Registered Nurse in charge of ECT. She confirmed that the Time Out procedure was not documented in the patient's clinical record.

Based on record review and interview, the governing body failed to ensure that contract services were included in the facility's Quality Assessment and Performance Improvement (QAPI) Program.

Findings include:

Record review on 12-10-14 of a list of contracted services provided by Chief Executive Officer (CEO) # 50 revealed laboratory and radiology services were contracted services.

Record review on 12-12-14 of facility "Performance Improvement /Risk Management Plan," dated 2014 read: "..Roles & Responsibility: The Governing Body...bears the ultimate responsibility for assuring the quality and appropriateness of patient care services provided by its medical , allied, other professionals and support services....Scope and Organization:...The Department Director of each service shall ensure an on-going and systematic process for monitoring and evaluating the quality and appropriateness of the patient care provided, the following support services shall participate and/or submit report: ...11. Contract Diagnostic Services ( lab, radiology)...."

Record review of the facility Performance Improvement Council meeting minutes for 2014 failed to reveal any documented performance improvement quality indicators, data, or discussion of the contract services of laboratory and radiology.

Interview on 12-12-14 at 11:30 a.m. with Quality/Risk Manager # 62, he stated the facility had not included laboratory and radiology services into the QAPI program but would correct this immediately.

Based on record review and interview, the facility failed to ensure medical record entries were complete and authenticated in writing by the person responsible for providing the information for 15 of 31 patients (#'s 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 32, 33, 36, 37, and 22) whose records were reviewed.

Findings include:

Patient #3

Record review of Patient #3's medical record on 12/9/14 revealed he was admitted on 12/4/14 with a diagnosis of psychotic disorder with delusions. The History and Physical (H&P) in the medical record had not been filled out. There was no documentation on the record, in the Nurses' Notes or Progress notes why the patient did not have a H&P.

During an interview on 12/9/14 with RN #65, she was asked why Patient #3 did not have a History and Physical. She said some patients refused to allow the physician to get a physical. She did not know why Patient #3 did not have a H&P.

Record review of the patient's Master Treatment Plan dated 12/6/14 under the section for Initial Discharge Planning revealed Community Resources and Placement were blank.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed the patient presented with thought broadcasting, illogical speech, and agitation. The patient was admitted for delusional thinking and wanting to kill his mother and sister. MD #91 signed the Psychiatry portion of the plan, but did not write a target date or frequency for prescribing medications or individual sessions to monitor medication compliance, effects for targeted behaviors and side effects.

The section for Clinical Services was blank.

Patient #4

Record review of Patient #4's medical record revealed he was admitted on 12/4/14 with diagnosis of psychosis. The patient stated he walked in front of a moving car.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed he presented with agitation. Under "Description" the lines were blank. The Psychiatry section was blank.

Patient #5

Record review of Patient #5's medical record revealed she was admitted on 12/2/14 with a diagnosis of Bipolar disorder. The patient's son called 911 because she threatened to kill him.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed she presented with magical thinking, persecution, agitation, and bizarre behaviors/mannerisms. The Psychiatry section was blank.

Patient #6

Record review of Patient #6's medical record revealed she was admitted on 11/10/14 with diagnoses that included recurrent depression and psychosis. The patient had delusional thinking. There was no Initial Psychiatric Evaluation.

The dictated initial Psychiatric Evaluation was found in Medical Records. Record review revealed there was nothing noted for estimated intellectual functioning, memory functioning, orientation, strengths and liabilities.

Record review of Patient #6's Master Treatment Plan revealed it was blank.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed she admitted with auditory hallucinations, delusions of grandeur, hyper religiosity, and bizarre behaviors/mannerisms. The Psychiatry section was blank. The Clinical Services interventions were not signed by the therapist.

Interview on 12/9/14 at 2:45 p.m. with RN #56, Director of Clinical Services, she said the therapist filled out the Master Treatment Plan. The nurses were responsible for filling out the top section of the individual treatment plan that was used for each patient depending on their diagnosis or symptoms, such as "Psychosis". Then each person on the Interdisciplinary Team (IDT) was to fill out their sections such as the psychiatrist, the recreational therapist, the therapist and then the nurses on the back sheet. When she was asked why Patient #6 did not have a Master Treatment Plan, she said probably because the patient did not have an initial psychiatric evaluation in the chart and the therapist needed that to fill out the diagnoses for the Master Treatment Plan. She could not say why the strength, limitation and initial discharge planning sections of the Master Treatment Plan could not be filled out.

Patient #7

Record review of Patient #7's medical record revealed he was admitted on 11/23/14 with diagnoses of Bipolar disorder and depression. There was no Initial Psychiatric Evaluation.

The dictated initial Psychiatric Evaluation was found in Medical Records. Record review revealed there was nothing noted for estimated intellectual functioning, memory functioning, orientation, strengths and liabilities.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Depression revealed the patient presented with sleep disturbance, poor hygiene, appetite disturbances, agitation/irritability, and felt hopeless/helpless. The top section for Description of the patient and the long and short term goals were blank. The Psychiatry, Recreational Therapy, and Clinical Services sections were blank.

Record review of Patient #7's Adult Multidisciplinary Treatment Plan for Mood Disturbance with Depression and Anxiety checked revealed the top sections for patient presentation and description were blank.

Record review of Patient #7's Adult Multidisciplinary Treatment Plan for Psychosis revealed the top section for patient presentation and description were blank. The interventions under Clinical Services were not signed.

Patient #8

Record review of Patient #8's medical record revealed she was admitted on 11/30/14 with a diagnosis of Bipolar disorder.

Record review of Patient #8's Adult Multidisciplinary Treatment Plan for Mood Disturbance with Depression and Anxiety checked revealed the patient presented with anxiety, poor hygiene, feels hopeless/helpless, and agitation/irritability. The top section for Description of the patient was blank. MD #91 signed the Psychiatry portion of the plan, but did not write a target date or frequency for prescribing medications or individual sessions to monitor medication compliance, effects for targeted behaviors and side effects.

Patient #9

Record review of Patient #9's medical record revealed she was admitted on 11/26/14 with diagnoses of anxiety, panic attacks and suicidal ideation.

Record review of the patient's Progress Notes revealed a handwritten Initial Psychiatric Evaluation. The physician's handwriting was difficult to read. Record review revealed there was nothing noted for estimated intellectual functioning, memory functioning, orientation, strengths and liabilities.

Record review of Patient #9's Adult Multidisciplinary Treatment Plan for Mood Disturbance with Depression and Anxiety checked revealed the patient presented with anxiety, sleep disturbance, racing thoughts, crying spells, feels hopeless/helpless, and low self-esteem. The Psychiatry section was signed by MD #90, but he did not write a target date or frequency for prescribing medications or individual sessions to monitor medication compliance, effects for targeted behaviors and side effects.

Interview on 12/11/14 at with RN #56, Director of Clinical Services, she said she found the initial psychiatric evaluations for Patients #6 and #7 in Medical Records. She came back with a copy of the dictated Psychiatric Evaluation for Patient #6 dated 11/10/14 at 7:16 a.m. and one for Patient #7 dated 11/24/14 at 7:17 a.m. She agreed that the record served no function for the patients since it was not on the medical record. She said she thought the problem was a breakdown in Medical Records from the evaluation being dictated, transcribed, and then getting it put in the medical record on the unit.

Patient # 10

Record review of Patient #10's medical record revealed she was admitted on 12-03-14 with a diagnosis of depression and history of suicide attempt and cutting.

Record review of the patient's Youth Multidisciplinary Treatment Plan for Suicidal ideation (SI) revealed this problem was identified by Physician # 52 on admission ( 12-3-14). The Therapist and Clinical Services portions of the Suicidal ideation treatment plan were blank.

Continued record review of Patient # 10's Youth Treatment Plan revealed the plan was reviewed and updated on 12-04-14 and 12-09-14. On both of these dates, the Discharge Planning/update section was left blank. On the 12-09-14 update, it read: "...patient endorses SI and homicidal ideation ( HI)...the voices are back.."


Patient # 11

Record review of Patient #11's medical record revealed he was admitted on 12/5/14 with a diagnoses of bipolar disorder and impulse control disorder.

Record review of the patient's Youth Multidisciplinary Treatment Plan for Suicidal ideation (SI) revealed this problem was addressed by Nursing and Recreational Therapy on 12-05-14. The Psychiatry MD and Clinical Services portions of the SI Treatment Plan were left blank.

Continued review of Patient # 11's Youth Multidisciplinary Treatment Plan revealed the problem Physical Aggression was identified by nursing on 12-05-14. The long term and short term goals sections were left blank. The Psychiatry MD and Clinical Services portions of the Physical Aggression Treatment Plan were left blank.

Patient # 12

Record review of Patient #12's medical record revealed she was admitted on 12/5/14 with a diagnoses of bipolar disorder , increasing aggression, and cutting behaviors.

Record review of the patient's Youth Multidisciplinary Treatment Plan for depression revealed this problem was addressed by Clinical Services on 12-08-14. The Psychiatry MD and Nursing Diagnosis portions of the depression treatment plan were left blank.

Continued review of Patient # 12's Youth Multidisciplinary Treatment Plan revealed the plan was updated and reviewed on 12-09-14. The Discharge planning/update section of this review was left blank.


Patient # 32 ( outpatient clinic- southwest region)

Record review of Patient #32's medical record revealed he was admitted to outpatient services on 12/3/14 with a diagnosis of episodic mood disorder and history of arrest for assault with a deadly weapon.

Record review of the patient's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Disturbance: Depression and Anxiety revealed this problem was addressed by Clinical Services and Nursing on 12-03-14. The Psychiatry MD portion of the this treatment plan was left blank.

Patient # 33 ( outpatient clinic- southwest region)

Record review of Patient #33's medical record revealed she was admitted to outpatient services on 12/2/14 with a diagnoses of major depressive disorder and suicidal ideation.

Record review of the patient's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Depression and Anxiety revealed this problem was addressed by Nursing ; there was no signature and date recorded on the Nursing Diagnosis section.

Interview on 12-11-14 at 2:40 p.m. with Registered Nurse (RN) # 102, she stated the blank areas should have been completed and that all medical record entries should be dated.

Patient # 36

Record review of Patient #36's medical record revealed he was admitted on 12/5/14 with a diagnoses of psychosis and seasonal affective disorder.

Record review of the patient's Master Treatment Plan dated 12/8/14 under the section for Initial Discharge Planning revealed Community Resources and Placement were blank. In addition, the section asking if patient/family wanted primary physician notified of hospital admission was left blank.


Patient # 37

Record review of Patient #37's medical record revealed she was admitted on 12/6/14 with a diagnoses of mood disorder and aggression.

Record review of the patient's Master Treatment Plan dated 12/8/14 under the section for Initial Discharge Planning revealed "Barriers to Discharge" was blank. In addition, the section asking if patient/family wanted primary physician notified of hospital admission was left blank.

Further review of the Patient # 37's Master Treatment Plan dated 12/8/14 under the section for Psychiatry revealed this section was left blank: no pre-printed interventions checked or dated by MD # 90.

Review of "Seclusion and Restraint Hourly Flowsheet" for Patient # 37, dated 12-09-14, revealed patient was placed in a physical restraint at 1215 and then into seclusion from 1216 until 1230. Sections for vital signs to be recorded at 1215 and 1230 were left blank and it was not documented the patient's family/guardian was notified in the section provided. Review of "Seclusion/Restraint Patient Debriefing"form, dated 12-09-14 revealed the section for the patient's signature was left blank.

Review of Patient # 37's Youth Treatment Plan "Update & Review" forms revealed:
"Discharge Impediments" section: left blank on 10-07-14 and 10-09-14;
"DischargePlanning/Update" section: left blank on 10-07-14, 10-09-14, and 10-14-14.

Interview on 12-11-14 at 9:45 a.m. with Children's Unit charge nurse Registered Nurse (RN) # 75, he stated the vital signs should have been taken and recorded; notification of the patient's family/guardian should have been documented; and Patient # 37's signature should have been obtained on the debriefing form.

Patient # 22

Record review of Patient #22's medical record revealed he was admitted on 10/02/14 with a diagnoses of mood disorder and antisocial traits.

Record review of the patient's Master Treatment Plan dated 10/06/14 under the section for Initial Discharge Planning revealed : Community Resources, Family Involvement, and Medical Services sections were all left blank.

Further review of the Patient # 22's Youth Multidisciplinary Treatment Plan : Suicidal Attempt was initiated by MD # 91 on 10-12-14. The long-term and short term goals sections were blank. The section for Clinical Services was blank.

Further review of the Patient # 22's Youth Multidisciplinary Treatment Plan: Depression, dated 10-12-14 revealed the long-term and short term sections goals were blank.

Based on interview and record review, the facility (out-patient location southwestern [SW] region) failed to ensure adequate life safety from fire by failing to conduct quarterly fire drills for the last quarter of 2013 and the first three (3) quarters of 2014.

Findings include:

Interview on 12-11-14 at 2:45 p.m. with outpatient location (SW) Clinic Manager # 103, she stated the facility conducted fire drills but she could not recall the last drill they had.

Review review on 12-11-14 of facility fire drill report records revealed the last documented fire drill conducted at the facility was dated 09-20-2013. Facility staff was unable to produce any additional documentation prior to surveyor exiting the facility on 12-11-14.

Record review on 12-11-14 of outpatient location (SW) general policies (untitled & undated), read: "...4. Fire Extinguishers/Fire Drills:.. iv. Staff will conduct fire drills at least quarterly to remind all staff and patients the need for fire safety and egress from the building."

Based on observation, interview and record review, the facility failed to operationalize its Policy and Procedure to ensure Facility's direct care staff washed/clean hands in between patient care in 2 of 2 patients observe during Electroconvulsive Therapy from 35 sampled patients. Patient #s 7 and 19; The facility's staff failed to clean and disinfect equipment in between patient care during Electroconvulsive therapy.
Based on observation, interview, and record review, the facility failed to develop a system for identifying and controlling possible infections by ensuring:
-The environment in 2 of 2 out-patient facilities inspected was clean and sanitary
-The enviornment on Units 6, 7, and 8 was clean and sanitary
-Medication carts and glucometers were cleaned timely and appropriately for 3 of 8 units (Units 1, 2, and 3).
Findings
Review on 12/10/2014 of the facility's current policy and procedure on Gloves Disposable, Last revised 01/2013 directed staff as follows: " Gloves must be worn when handling blood, blood specimen, blood soiled items, body fluids, excretions, secretions, mucus membranes, tissues, organs, or moist body substance, surfaces, materials and objects exposed to the aforementioned items.
Hypoallergenic gloves, glove liners, powerless gloves or other similar alternatives shall be readily accessible, as appropriate to those employees who are allergic or in anyway, cannot utilize the general gloves normally provided.
Gloves should be changed and hand washed after direct contact with patient's blood, body fluids, excretions, secretions, mucus membranes, tissues, organs or any moist body substance.
Gloves must be changed and hands washed, between patients and procedures. Gloves do not replace hand hygiene, such as hand washing and hand decontamination. "
Patient #7
Observation on 12/10/2014 at 9.22 a.m. revealed Anesthesiologist #77 was observed in the Electroconvulsive Therapy suite preparing Patient #7 for ECT.
Observation revealed the Anesthesiologist pulled up, prepared and administered intravenous medication to patient #7, placed an airway mouth guard in the patient's mouth, used the ambu bag (manual breathing unit) to bag the patient, and removed the mouth guard airway from the patient's mouth. He then retrieved the patient's anesthesia record and wrote on the record with his ungloved contaminated hands. He transferred the patient to the post anesthesia cubicle, completed the post anesthesia assessment and left the cubicle. Anesthesiologist #77 then proceeded to the chairside of patient #19 where he touched and examined the patient with his contaminated hands.
Anesthesiologist (#77) did not wash/ clean his contaminated hands in between patients.
Patient #19
Observation on 12/10/2014 at 9.35 a.m revealed Anesthesiologist #19 was observed in the Electroconvulsive Therapy suite preparing for ECT on Patient #19.
Observation revealed the Anesthesiologist pulled up, prepared and administered intravenous medication to patient #19, placed an airway mouth guard in the patient's mouth, used the ambu bag (manual breathing unit) to bag the patient
Observation revealed the patient's intravenous site to her right upper arm became infiltrated.
Registered Nurse (#78) attempted cannulating the patient without success. She then removed the cannula and walked over to the clean cart where she picked up a cannula from the stock of cannulas with her contaminated gloved hands.
Observation revealed Anesthesiologist ( #77) continued providing care to the patient, pulled up, prepared and administered additional intravenous medication to patient #19, used the ambu bag (manual breathing unit) to bag the patient, and removed the mouth guard airway from the patient's mouth, touched the sclera of the patient's eye with his bare hands. He then retrieved the patient's anesthesia record and wrote on the record with his contaminated hands. He transferred the patient to the post anesthesia cubicle, completed the post anesthesia assessment and left the cubicle. Anesthesiologist #77 then proceeded to the ECT unit where he retrieved his personal belongings. He did not wash or clean his contaminated hands.
Terminal cleaning of ECT unit.
Review of the facility's current Policy on Cleaning of Medical Equipment, Last Reviewed Date 01/2014, direct staff as follows:
"Items listed below are considered non- critical and must be disinfected daily and after each patient use. Patient equipment managed by patient care units or services must be wiped down by unit staff with West Oak Hospital approved disinfectant daily and when visible soiled. These items include but are not limited to. Blood pressure machines, Glucometers, Pulse oximeters, Stethoscopes."
Observation on 12/10/2014 at 9.22 a.m revealed Anesthesiologist #77 was observed in the Electroconvulsive therapy suite conducting ECT on patient #7.
After the procedure the facility's staff discarded the mask attached to the ambu bag, discarded the electrodes from the monitor and set up new mask and electrodes for an on-coming patient. The staff did not clean blood pressure cuffs, EKG machine and leads, Pulse Oximeters. The staff did not clean the unit in between procedure.
Observation on 12/10/2014 at 9.35 a.m revealed Anesthesiologist #19 was observed in the Electroconvulsive Therapy suite preparing for ECT on Patient #19. The unit was not terminally cleaned in between patient #7 and Patient #19.
Interview on 12/10/2014 10.00 a.m with Registered Nurse (#78), the Surveyor informed her that she had cross contaminated clean and contaminated areas/ equipment, using her contaminated hands with clean supply and that the unit was not cleaned in between patients. She stated " we will make sure we clean the unit. "
Environment
Out-patient Clinic (western region)
Observation on 12/11/2014 at 2.45 p.m. of the facility's out-patient clinic located in western region revealed the carpet in the hallway across from the nurses' station had approximately 5 feet circumference of water stain. The ceiling tiles above the carpet had yellow brown discoloration.
Observation of the ceiling tiles adjacent to the patient's bathroom revealed large yellow brown water stains.
Observation of the nurses' examination rooms revealed paper carton boxes with plates, cups, toilet papers and napkins sitting directly on the floor. Clients bags and knapsacks were stored directly on the floor.
Interview with the Facility's Manager on 12/11/2014 at 3:10 p.m. revealed the roof of the building is flat and so the roof leaks at time.

Environment:

Outpatient Clinic (southwestern region) :

Storage/Labeling of Lab Specimens & Cleaning of Multi-Patient Use Equipment :

Observation on 12-11-14 at 2:45 p.m. in a refrigerator in Registered Nurse (RN) # 102's office revealed four(4) plastic specimen containers with semi-legible patient names written on the containers with black marker. The containers appeared to contain urine; 3 of the 4 specimen containers were not in plastic biohazard bags.

Interview at the time of observation with clinic Registered Nurse (RN) # 102, she stated the containers were urine samples and said they should have been in biohazard bags and properly labeled.

Further interview at this same time with RN # 102, she stated the electronic blood pressure machine cuff was used for multiple patients every day. When asked how the blood pressure cuff was sanitized between patients, she acknowledged the cuff was not cleaned between patients.

Record review on 12-11-14 of facility general operating policies ( untitled/undated), read: "...Vlll Medical issues: Nursing Functions at the Clinic:...H. The nurse will be responsible for the sharps container, biohazardous waste...Infection Control: B. The nurse will be responsible for the infection control process at the clinic..."

Observation on 12-11-14 at 3:00 p.m. revealed multiple, widespread large dark stains on the carpet in the hallway and in two (2) of the group meeting rooms.

Interview on 12-11-14 at 3:45 p.m. with Clinic Manager # 103 she stated the carpets had been cleaned before but the stains always returned. There had been some mention of replacing the flooring but she was unsure when this would happen.

Further observation at this outpatient clinic on 12-11-14 revealed 10 to 12 cardboard boxes stored directly on the floor in 2 corners of of a group meeting room. In addition, there were 4 boxes of plastic cups and plates stored directly on the floor of the clinic kitchen area. The area under the sink was noted to have an approximate 8 inch brown stain .

Hospital Units

Units 6, 7 and 8

Observations on 12-09-14 between 10:35 a.m. and 11:45 a.m. revealed a boy's and a girl's restroom on each of the following units: Units 6, 7, and 8.

Further observation in each of the restrooms on all three units revealed two (2) shower stalls and a sink area. In each of the shower stalls and under the sinks, there were multiple areas noted in which the grout between the floor tiles had dark brown stains and "build up."

Interview on 12-09-14 at 10:45 a.m. with Mental Health Worker #72 she said that housekeeping cleaned the showers daily and as needed.

Interview with the CEO #50 on the morning of 12-11-14, he stated all of the showers and restroom floors had been professionally cleaned and treated on 12-10-14.

Observation on 12-12-14 at 11 a.m. on Unit 7 revealed brown stained areas under the sinks. A pencil placed in the grout line yielded a large amount of brown grime and dirt "build up."

Medication Carts

Unit 2

Observation on 12/10/14 at 9:35 a.m. of the Unit 2 medication cart revealed a layer of dust and dirt on the leg supports over the wheels. The bottom three drawers had a layer of dust and debris in each drawer.
There was a section of 20 individual drawers for individual patient medications. Each drawer had a thick build up of adhesive tape residue.

Interview at this time with RN (Registered Nurse) #63, when she was asked how often she cleaned the medication cart, said she cleaned it weekly.

Unit 1

Observation on 12/10/14 at 9:45 a.m. of the Unit 1 medicaion cart revealed a layer of dust and dirt on the leg supports over the wheels. The bottom three drawers had a layer of dust and debris in each drawer. There was a section of 20 individual drawers for individual patient medications. Each drawer had a thick build up of adhesive tape residue.

Interview at this time with RN #108, she said she cleaned the medication cart everyday when she used it.

Unit 3

Observation on 12/09/2014 at 1:50 p.m. on Unit 3 of the facility's medication room revealed two medication carts stored in the room. Observation of one of the medication carts revealed the top drawer of the cart contained oral medications of Tylenol 325 mgs in paper packets, Motrin, Metformin, Vitamin tablet in paper packet, stored together with hydrocortisone cream and inhalers ( flonaze nasal spray) albuterol inhaler and Triple antibiotic ointment. The drawer where the medications were stored had an accumulation of dirt and grime.
Also stored in the room was a suction machine. The machine and cart had a layer of dirt and grime on it.
Observation revealed when the Licensed Nurse turned the machine on to check for its function, dust balls filtered in the air from the suction canister.

Glucometers

Unit 2

Observation on 12/101/14 at 9:35 a.m. of the medication room on Unit 2 revealed an Ever Clear glucometer.

Interview at this time with RN #63, she said she cleaned the glucometer with an alcohol swab.

Unit 1

Observation on 12/10/14 at 9:45 a.m. of the medication room on Unit 1 revealed an Ever clear glucometer.

Interview at this time with RN #108, she said she cleaned the glucometer with an alcohol swab.

Record review of the Ever Clear manufacturer's instructions for cleaning revealed they recommended wiping the glucometer with a 10% bleach solution.

Based on record review and interview, the facility failed to ensure 2 of 7 patients reveiwed (#'s 6 and 7) on Units 1 and 2 had a psychiatric evalutation in their medical record to be used to form a treatment plan as evidenced by:

Patient's #6 and #7's initial psychiactric evaluations were not in their medical records two to four weeks after they were admitted.

This failure potentially results in a lack of identification of pathology, which may be pertinent to the current mental illness.

Findings include:

Patient #6

Record review on 12/9/14 of Patient #6's medical record revealed she was admitted on 11/10/14 with diagnoses of recurrent depression and psychosis. The patient's admitting physician was MD #89.

Further review of Patient #6's medical record revealed there was no initial psychiatric evaluation.

Interview on 12/9/14 at 1:35 p.m. with RN #56, Director of Clinical Services, she was informed there was no initial psychiatric evaluation in Patient #6's chart. She looked through the chart. She was not able to find the record. She said MD #89 dictated his psychiatric evaluations.

Patient #7

Record review on 12/10/14 of Patient #7's medical record revealed he was admitted on 11/23/14 with diagnoses of Bipolar Disorder and depression. The patient's admittin physician was MD #89.

Further review of the patient's record revealed there was no initial psychiatric evaluation.

Interview on 12/10/14 at 11:10 a.m. with RN (Registered Nurse) #95, Infection Control nurse, she was asked if she could find the initial psychiatric evaluation for Patient #6. She looked through the patient's medical record. She said the patient's Physician, MD #89, liked to dictate his psychiatric evaluations. She said she could not find the record.

Interview at this time with RN #56, Director of Clinical Services, she said she would go to medical records to see if the records were there. She came back with a copy of the dictated Psychiatric Evaluation for Patient #6 dated 11/10/14 at 7:16 a.m. and one for Patient #7 dated 11/24/14 at 7:17 a.m. She agreed that the record served no function for the patients since it was not on the medical record. She said she thought the problem was a breakdown in Medical Records from the evaluation being dictated, transcribed, and then getting it put in the medical record.

Record review of the facility's Rules and Regulations incorporated by reference into the Medical Staff Bylaws revealed the following:

"2.8 The Psychiatric Evaluation and Mental Status examination shall, in all cases, be completed and dictated within 24 hours after admission of the patient..."

Based on record review and interview, the facility failed to ensure 3 of 7 patients reviewed (#'s 6, 7, and 9) on Units 1 and 2 received a psychiatric evaluation that estimated intellectual functioning, memory functioning and orientation as evidenced by:

Patients #'s 6, 7, and 9 had initial psychiatric evaluations that did not include intellectual functioning, memory functioning and orientation as per regulation and the facility's policy and procedure.

These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness and compromise future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

Patient #6

Record review on 12/9/14 of Patient #6's medical record revealed she was admitted on 11/10/14 involuntarily at 2:04 p.m. with diagnoses of recurrent depression and psychosis. The patient's admitting physician was MD #89.

Record review of Patient #6's dictated initial psychiatric evaluation by MD #89 revealed it was dictated on 11/10/14 at 7:16 a.m. and transcribed on 11/10/14 at 8:04 a.m. (7 hours before the patient was admitted) There was nothing noted for estimated intellectual functioning, memory functioning and orientation.

Patient #7

Record review on 12/10/14 of Patient #7's medical record revealed he was admitted on 11/23/14 voluntarily at 7:49 p.m. with diagnoses of Bipolar Disorder and depression. The patient's admitting physician was MD #89.

Record review of the patient's dictated initial psychiatric evaluation by MD #89 revealed it was dictated on 11/24/14 at 7:17 a.m. and transcribed on 11/24/14 at 7:54 a.m. There was nothing noted for estimated intellectual functioning, memory functioning and orientation.

Patient # 9

Record review on 12/10/14 of Patient #9's medical record revealed she was admitted on 11/26/14 voluntarily at 8:12 p.m. with diagnoses of anxiety, panic attacks and suicidal ideation.

Record review of the patient's Progress Notes revealed a handwritten initial psychiatric evaluation dated 11/27/14. There was nothing noted for estimated intellectual functioning, memory functioning and orientation.

Interview on 12/11/14 at 11:15 a.m. with RN #56, Director of Clinical Services, when she was shown the missing items on the initial psychiatric evaluation, stated she understood and said the physician's must not be dictating from the facility's formatted sheet that includes all the above areas.

Record review of the facility's Medical Rules and Regulations for 2.8.1 revealed the following:
"The Psychiatric Evaluation should include: ...
b. Mental status evaluation, including description of attitudes and behavior and estimate of intellectual functioning, memory functioning, and orientation..."

Based on record review and interview, the facility failed to ensure 3 of 7 patients reviewed (#'s 6, 7, and 9) on Units 1 and 2 received a psychiatric evaluation that included an inventory of strengths and liabilities as evidenced by:

Patients #'s 6, 7, and 9 had initial psychiatric evaluations that did not include strengths and liabilities that could be used in the treatment plan as per regulation and the facility's policy and procedure.

These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness and compromise future comparative re-examinations to assess patient's response to treatment interventions.


Findings include:

Patient #6

Record review on 12/9/14 of Patient #6's medical record revealed she was admitted on 11/10/14 involuntarily at 2:04 p.m. with diagnoses of recurrent depression and psychosis. The patient's admitting physician was MD #89.

Record review of Patient #6's dictated initial psychiatric evaluation by MD #89 revealed it was dictated on 11/10/14 at 7:16 a.m. and transcribed on 11/10/14 at 8:04 a.m. (7 hours before the patient was admitted) There was nothing noted for strengths and liabilities.

Patient #7

Record review on 12/10/14 of Patient #7's medical record revealed he was admitted on 11/23/14 voluntarily at 7:49 p.m. with diagnoses of Bipolar Disorder and depression. The patient's admitting physician was MD #89.

Record review of the patient's dictated initial psychiatric evaluation by MD #89 revealed it was dictated on 11/24/14 at 7:17 a.m. and transcribed on 11/24/14 at 7:54 a.m. There was nothing noted for strengths and liabilities.

Patient # 9

Record review on 12/10/14 of Patient #9's medical record revealed she was admitted on 11/26/14 voluntarily at 8:12 p.m. with diagnoses of anxiety, panic attacks and suicidal ideation.

Record review of the patient's Progress Notes revealed a handwritten initial psychiatric evaluation dated 11/27/14. There was nothing noted for strengths and liabilities.

Interview on 12/11/14 at 11:15 a.m. with RN #56, Director of Clinical Services, when she was shown the missing items on the initial psychiatric evaluation, stated she understood and said the physician's must not be dictating from the facility's formatted sheet that includes the above areas.

Record review of the facility's Medical Rules and Regulations for 2.8.1 revealed the following:
"The Psychiatric Evaluation should include: ...
m. Patient strengths and liabilities...."

Based on observation, record review and interview, the facility failed to ensure each patient had complete and comprehensive treatment plan for 14 of 31 active patients reviewed (#'s 3, 4, 5, 6, 7, 8, 9, 28, 29, 10, 11, 12, 32, and 33).

These failures result in a treatment plan that fails to reflect a multidisciplinary treatment approach, failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include:

Patient #3

Record review of Patient #3's medical record revealed he was admitted on 12/4/14 with a diagnosis of psychotic disorder with delusions.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed the patient presented with thought broadcasting, illogical speech, and agitation. The patient was admitted for delusional thinking and wanting to kill his mother and sister. MD #91 signed the Psychiatry portion of the plan, but did not write a target date or frequency for prescribing medications or individual sessions to monitor medication compliance, effects for targeted behaviors and side effects.

The section for Clinical Services was blank.

Patient #4

Record review of Patient #4's medical record revealed he was admitted on 12/4/14 with diagnosis of psychosis. The patient stated he walked in front of a moving car.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed he presented with agitation. Under "Description" the lines were blank. The Psychiatry section was blank.

Patient #5

Record review of Patient #5's medical record revealed she was admitted on 12/2/14 with a diagnosis of Bipolar disorder. The patient's son called 911 because she threatened to kill him.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed she presented with magical thinking, persecution, agitation, and bizarre behaviors/mannerisms. The Psychiatry section was blank.

Patient #6

Record review of Patient #6's medical record revealed she was admitted on 11/10/14 with diagnoses that included recurrent depression and psychosis. The patient had delusional thinking.

Record review of Patient #6's Master Treatment Plan revealed it was blank.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Psychosis revealed she admitted with auditory hallucinations, delusions of grandeur, hyper religiosity, and bizarre behaviors/mannerisms. The Psychiatry section was blank.

Interview on 12/9/14 at 2:45 p.m. with RN #56, Director of Clinical Services, she said the therapist filled out the Master Treatment Plan. The nurses were responsible for filling out the top section of the individual treatment plan that was used for each patient depending on their diagnosis or symptoms, such as "Psychosis". Then each person on the Interdisciplinary Team (IDT) was to fill out their sections such as the psychiatrist, the recreational therapist, the therapist and then the nurses on the back sheet. When she was asked why Patient #6 did not have a Master Treatment Plan, she said probably because the patient did not have an initial psychiatric evaluation in the chart and the therapist needed that to fill out the diagnoses for the Master Treatment Plan. She could not say why the strength, limitation and initial discharge planning sections of the Master Treatment Plan could not be filled out.

Patient #7

Record review of Patient #7's medical record revealed he was admitted on 11/23/14 with diagnoses of Bipolar disorder and depression.

Record review of the patient's Adult Multidisciplinary Treatment Plan for Depression revealed the patient presented with sleep disturbance, poor hygiene, appetite disturbances, agitation/irritability, and felt hopeless/helpless. The top section for Description of the patient and the long and short term goals were blank. The Psychiatry, Recreational Therapy, and Clinical Services sections were blank.

Record review of Patient #7's Adult Multidisciplinary Treatment Plan for Mood Disturbance with Depression and Anxiety checked revealed the top sections for patient presentation and description were blank.

Record review of Patient #7's Adult Multidisciplinary Treatment Plan for Psychosis revealed the top section for patient presentation and description were blank.

Patient #8

Record review of Patient #8's medical record revealed she was admitted on 11/30/14 with a diagnosis of Bipolar disorder.

Record review of Patient #8's Adult Multidisciplinary Treatment Plan for Mood Disturbance with Depression and Anxiety checked revealed the patient presented with anxiety, poor hygiene, feels hopeless/helpless, and agitation/irritability. The top section for Description of the patient was blank. MD #91 signed the Psychiatry portion of the plan, but did not write a target date or frequency for prescribing medications or individual sessions to monitor medication compliance, effects for targeted behaviors and side effects.

Patient #9

Record review of Patient #9's medical record revealed she was admitted on 11/26/14 with diagnoses of anxiety, panic attacks and suicidal ideation.

Record review of Patient #9's Adult Multidisciplinary Treatment Plan for Mood Disturbance with Depression and Anxiety checked revealed the patient presented with anxiety, sleep disturbance, racing thoughts, crying spells, feels hopeless/helpless, and low self-esteem. The Psychiatry section was signed by MD #90, but he did not write a target date or frequency for prescribing medications or individual sessions to monitor medication compliance, effects for targeted behaviors and side effects.

Interview on 12/11/14 at 12:10 p.m. with RN #56, Director of Clinical Services, when asked about the psychiatrists leaving their sections blank, said MD #91 did not fill in the section on the individual treatment plans, but put the information in other parts of the patient's record.

Patient #28
On 12/11/2014 at 4:10 p.m. Patient #28 was observed in the Out Patient Psychiatric Unit The patient was alert and oriented to person place and time.

Interview on 12/11/2014 at 4:12 p.m. with the patient revealed, he was admitted to the facility because he was feeling hopeless, and needed help. He said he experiences thoughts of suicidal ideation but had not acted on it.

Review of the patient's clinical record ( Demographic Data) revealed the patient was admitted to the facility on 11/19/2014 with presenting symptom of depression, anxiety, and trauma. Complained of decreased concentration, fatigue and crying episode.

Review of the patient multidisciplinary Treatment Plan dated 11/21/14 and Treatment Plan, Up dates and Review, dated 11/26/2014 and 12/04/14 revealed no documented intervention by the patient psychiatrist.

Interview on 12/11/2014 with the Facility's Manager revealed the facility does Telemedicine, the Nurse and patients are generally in the room during Telemedicine. He said the physician does not come to the facility. He said the patient's clinical records are brought to the main campus to be signed by the psychiatrist, but this was not done.

Patient #29
Review of the patient's clinical record ( Demographic Data) revealed the patient was admitted to the facility on 12/03/2014

Review of the Patient's Psychosocial assessment dated 12/03/2014 revealed the patient was admitted with chief complaint of Depression, Anxiety, Suicidal thoughts, decreased energy, decreased motivation, insomnia, early morning awakening and thoughts of dying

Review of the patient's Multidisciplinary Treatment Plan dated 12/03/14 and Treatment Plan, Up dates and Review, dated 12/04/2014 revealed no documented involvement by the patient's psychiatrist.

Interview on 12/11/2014 with the Facility's Manager revealed the involvement of the patient psychiatrist was overlooked.

Patient # 10

Record review of Patient #10's medical record revealed she was admitted on 12-03-14 with a diagnosis of depression and history of suicide attempt and cutting.

Record review of the patient's Youth Multidisciplinary Treatment Plan for Suicidal ideation (SI) revealed this problem was identified by Physician # 52 on admission ( 12-3-14). The Therapist and Clinical Services portions of the Suicidal ideation treatment plan were blank.

Continued record review of Patient # 10's Youth Treatment Plan revealed the plan was reviewed and updated on 12-04-14 and 12-09-14. On both of these dates, the Discharge Planning/update section was left blank. On the 12-09-14 update, it read: "...patient endorses SI and homicidal ideation ( HI)...the voices are back.."

Patient # 11

Record review of Patient #11's medical record revealed he was admitted on 12/5/14 with a diagnoses of bipolar disorder and impulse control disorder.

Record review of the patient's Youth Multidisciplinary Treatment Plan for Suicidal ideation (SI) revealed this problem was addressed by Nursing and Recreational Therapy on 12-05-14. The Psychiatry MD and Clinical Services portions of the SI Treatment Plan were left blank.

Continued review of Patient # 11's Youth Multidisciplinary Treatment Plan revealed the problem Physical Aggression was identified by nursing on 12-05-14. The long term and short term goals sections were left blank. The Psychiatry MD and Clinical Services portions of the Physical Aggression Treatment Plan were left blank.


Patient #12

Record review of Patient #12's medical record revealed she was admitted on 12/5/14 with a diagnoses of bipolar disorder , increasing aggression, and cutting behaviors.

Record review of the patient's Youth Multidisciplinary Treatment Plan for depression revealed this problem was addressed by Clinical Services on 12-08-14. The Psychiatry MD and Nursing Diagnosis portions of the depression treatment plan were left blank.

Continued review of Patient # 12's Youth Multidisciplinary Treatment Plan revealed the plan was updated and reviewed on 12-09-14. The Discharge planning/update section of this review was left blank.


Patient # 32 ( outpatient clinic- southwest region)

Record review of Patient #32's medical record revealed he was admitted to outpatient services on 12/3/14 with a diagnosis of episodic mood disorder and history of arrest for assault with a deadly weapon.

Record review of the patient's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Disturbance: Depression and Anxiety revealed this problem was addressed by Clinical Services and Nursing on 12-03-14. The Psychiatry MD portion of the this treatment plan was left blank.

Patient # 33 ( outpatient clinic- southwest region)

Record review of Patient #33's medical record revealed she was admitted to outpatient services on 12/2/14 with a diagnoses of major depressive disorder and suicidal ideation.

Record review of the patient's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Depression and Anxiety revealed this problem was addressed by Nursing ; there was no signature and date recorded on the Nursing Diagnosis section.

Interview on 12-11-14 at 2:40 p.m. with Registered Nurse (RN) # 102, she stated the blank areas should have been completed and that all medical record entries should be dated.

Record review of the facility's Policy and Procedure for Master Treatment Plan/Reassessment reviewed on 7/12 revealed the following:

"Purpose:
1. To provide documentation in the patient record of the care and treatment in all inpatient services,...that is planned and provided as interdisciplinary, collaborative manner by qualified individuals. To provide documentation in the patient record that the patient's progress is periodically evaluated against care goals and the plan of care, and when indicated, the plan or goals are revised.

Steps:...
10. There are treatment plans which are individualized for patients are to be used by each discipline that will be seeing the patient. Each discipline is to address the objectives that are to be met by the patient in their modality..."

Based on record review and interview, the facility failed to ensure the treatment plans for 14 of 31 sampled patients (#'s3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 32, 33, 24, and 35) identified active treatment measures that addressed the individual patient's specific problems and treatment. Instead, the treatment plans either listed routine and generic discipline functions written as treatment interventions or listed general group/activities to be provided for the patients as the interventions. The listed groups/activities, by title only, failed to include the specific focus or duration of treatment.

These failures result in treatment plans that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include:

Patient #3

Record review of Patient #3's Adult Multidisciplinary Treatment Plan, Psychosis, dated 12/4/14 under Treatment Modalities and Interventions listed the following:
Psychiatry - nothing was listed by MD #91
Recreational Therapy - Recreational/leisure education therapy 3 to 5 times per week
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form.
Clinical Services - was blank
Nursing Diagnosis: Risk for Violence - Self or Other Directed - "Encourage pt. (patient) to verbalize feelings and thoughts to staff. Ongoing and every shift.

The treatment plan did not specifically address the patient's issues of thought broadcasting, illogical speech, and agitation. The patient was admitted for delusional thinking and wanting to kill his mother and sister.

Patient #4

Record review of Patient #4's Adult Multidisciplinary Treatment Plan, Psychosis, dated 12/4/14 under Treatment Modalities and Interventions listed the following:
Psychiatry - the section was blank
Recreational Therapy - Recreational/leisure education therapy 3 to 5 times per week
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form
Clinical Services -
-Group therapy (GT) - pt. will engage in GT to increase knowledge and skills related to mental illness, including medication management and coping skills.
-Individual therapy (IT) - pt. will receive IT as needed to address individual needs and concerns.
-Family therapy (FT) - pt. will engage in at least one FT to facilitate positive communication and discuss discharge plans.

The treatment plan did not specifically address the patient's issues of agitation. There was no description for why the patient was admitted.

Patient #5

Record review of Patient #4's Adult Multidisciplinary Treatment Plan, Psychosis, dated 12/2/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - the section was blank
Recreational Therapy - Recreational/leisure education therapy 3 to 5 times per week
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form
Clinical Services
-Group therapy - pt. will engage in GT to increase knowledge and skills related to mental illness, including medication management
-Individual therapy - pt. will engage in IT to address individual needs and concerns
-Family therapy - pt. will engage in FT as needed to facilitate positive communication and discuss discharge plans.

The treatment plan did not specifically address the patient's issues of magical thinking, persecution, agitation, and bizarre behaviors/mannerisms. Under Description: "Pt dressed inappropriately & has tissue stuck in her hair." A short term goal was for the patient to journal twice a day for 5 days and report in group.

Patient #6

Record review of Patient #6's Adult Multidisciplinary Treatment Plan, Psychosis, dated 11/10/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - the section was blank
Recreational Therapy - Recreational/leisure education therapy 3 to 5 times per week
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form
Clinical Services
"IT= Discuss reasons for admission
FT = Discuss D/C (discharge) plan & relapse prevention
GT= Discuss triggers & coping mechanisms"

The treatment plan did not specifically address the patient's issues with hyper religiosity, auditory/visual hallucinations, delusions of grandeur, and bizarre behaviors/mannerisms. Under "Description" the patient denied audio/visual hallucination, had delusions of grandeur about owning various companies and deserving an inheritance from them. The only short term goal was for the patient to alert staff if she was experiencing any auditory/visual hallucinations.

Patient #7

Record review of Patient #7's Adult Multidisciplinary Treatment Plan, Mood Disturbance for Depression and Anxiety, dated 11/23/14 under Treatment Modalities and Interventions listed the following:

Recreational Therapy - Recreational/leisure education therapy 4 times per week
Clinical Services
"IT= Discuss reasons for admission
FT = Discuss D/C (discharge) plan & relapse prevention
GT= Identify triggers & coping skills"

Nursing Diagnosis:
- Encourage verbalization of feelings or frustrations. Document and help pt. to develop adaptive coping skills relevant for managing mood shifts.
-Encourage group participation

The front top section of the treatment plan was blank and did not address how the patient presented. Two goals were for the patient to walk 10-15 mins daily to reduce depression and anxiety and to report to group.

Record review of Patient #7's Adult Multidisciplinary Treatment Plan, Psychosis dated 11/23/14 under Treatment Modalities and Interventions listed the following:

Recreational Therapy - Reality Group 3 times a week.
Clinical Services
"IT= Identify reasons for admission
FT = Discuss D/C (discharge), relapse prevention
GT= Identify triggers and coping skills"

Nursing Diagnosis:

- Set limits with less restrictive actions and redirect pt.

The front top section of the treatment plan was blank and did not address how the patient presented. The short term goal was to "Refer to Mood Disturbance"

Patient #8

Record review of Patient #7's Adult Multidisciplinary Treatment Plan, Mood Disturbance, dated 11/30/14, under Treatment Modalities and Interventions listed the following:

Psychiatry - was signed but nothing was added or addressed.
Recreational Therapy - Recreational/leisure education therapy 3 times per week
Reality Group 4 times a week.
Clinical Services
-Group therapy (GT) - GT to increase knowledge and skills related to mental illness
-Individual therapy (IT) - IT as needed to address individual needs and concerns.
-Family therapy (FT) - FT to facilitate positive communication with family and discuss discharge plans.

The treatment plan did not specifically address the patient's issues with anxiety, poor hygiene, feels hopeless/helpless, and agitation/irritability. The one goal was for the patient to learn a positive coping skill and to use it a least once with a peer. There was no "Description" of why the patient was admitted.

Patient #9

Record review of Patient #9's Adult Multidisciplinary Treatment Plan, Mood Disturbance for Depression and Anxiety, dated 11/26/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - was signed but nothing was added or addressed.
Recreational Therapy - Recreational/leisure education therapy 4 times per week
Social skills Group 3 times a week.
Clinical Services - Pt. will attend therapeutic group to learn new coping skills.
Pt. will attend IT sessions to discuss reasons for admission
Pt. will attend FT to discuss discharge plans.
The treatment plan did not specifically address the patient's issues with anxiety, sleep disturbance, racing thoughts, crying spells, feels hopeless/helpless, and low self-esteem. The description of the patient was seeing things, sad, crying spells.

Patient #10

Record review of Patient #10's Youth Multidisciplinary Treatment Plan, Depression, dated 12/3/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - line drawn by MD # 52 down pre-printed interventions; no frequency identified for interventions.

Recreational Therapy - Coping Skills- pre-printed form; not individualized- 3 times per week.
Relaxation Therapy 1 to 2 times a week; preprinted on the form-not individualized.

Record review of Patient #10's medical record revealed she was admitted on 12-03-14 with a diagnosis of depression and history of suicide attempt and cutting.

Patient # 11

Record review of Patient #11's Youth Multidisciplinary Treatment Plan, Physical Aggression, dated 12/5/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - nothing was listed by MD #104
Recreational Therapy : Physical fitness- 4 times per week; this was on pre-printed form; not individualized.

Further review of Patient #11 Multidisciplinary Treatment Plan, Suicidal ideation, dated 12/4/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - nothing was listed by MD #104
Clinical Services - was blank
Recreational Therapy - Recreational/leisure education therapy ; this was on pre-printed form; not individualized; no frequency documented.

Record review of Patient #11's medical record revealed he was admitted on 12/5/14 with a diagnoses of bipolar disorder and impulse control disorder.

Patient #12

Record review of Patient #12 s Adult Multidisciplinary Treatment Plan, Mania, dated 12/8/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - line drawn by MD # 91 down pre-printed interventions; no frequency identified for interventions.
Recreational Therapy - Recreational/leisure education therapy 4 times per week. This was preprinted on the form.

Further review of Patient #12 s Adult Multidisciplinary Treatment Plan, Depression, dated 12/8/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - nothing was listed by MD #91
Recreational Therapy - Coping skills 3 times per week; this was on pre-printed form; not individualized.
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form.
Nursing Diagnosis: Risk for Violence - Self or Other Directed - this section was blank.

Record review of Patient #12's medical record revealed she was admitted on 12/5/14 with a diagnoses of bipolar disorder, increasing aggression, and cutting behaviors.


Patient # 32 ( outpatient clinic- southwest region)

Record review of Patient #32's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Disturbance: Depression and Anxiety, dated 12-03-14, under Treatment Modalities and Interventions listed the following:

Psychiatry - no interventions listed or checked by MD #105; no frequencies; no target dates.
Clinical Services: "group therapy to increase coping and increase mood;" no specific coping skills listed; not individualized.

Record review of Patient #32's medical record revealed she was admitted to outpatient services on 12/3/14 with a diagnosis of episodic mood disorder and history of arrest for assault with a deadly weapon.

Patient # 33 ( outpatient clinic- southwest region)

Record review of Patient #33's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Disturbance: Depression and Anxiety, dated 12-03-14, under Treatment Modalities and Interventions listed the following:

Psychiatry - no interventions listed or checked by MD #106; no frequencies or target dates documented.
Clinical Services: "group therapy to increase coping and increase mood;" no specific coping skills listed; not individualized.

Record review of Patient #33's medical record revealed she was admitted to outpatient services on 12/2/14 with a diagnoses of major mood disorder and suicidal ideation.


Patient # 34 ( outpatient clinic- southwest region)

Record review of Patient #34's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Disturbance: Depression and Anxiety, dated 12-01-14, under Treatment Modalities and Interventions listed the following:

Psychiatry - interventions dated on preprinted form by MD # 106; not individulaized ; no frquency of interventions.
Clinical Services: "group therapy to increase mood and coping skills;" no specific coping skills listed; not individualized.

Record review of Patient #34's medical record revealed she was admitted to outpatient services on 12/1/14 with a diagnoses of depression and panic attacks.

Patient # 35 ( outpatient clinic- southwest region)

Record review of Patient #35's Multidisciplinary Treatment Plan , Psychological Impairment: Mood Disturbance: Depression and Anxiety, dated 11-18-14, under Treatment Modalities and Interventions listed the following:

Psychiatry - nothing was listed by MD #106
Clinical Services: "group therapy to increase adaptive coping and increase mood;" no specific coping skills listed; not individualized.

Further review of Patient #35's medical record revealed she was admitted to outpatient services on 11/18/14 with a diagnoses of major mood disorder and suicidal ideation without a plan.

Interview on 12-11-14 at 2:45 p.m. with outpatient location (SW) Clinic Manager # 103, she stated the treatment plans could be more individualized.

Interview on 12/11/14 at 12:10 p.m. with RN #56, Director of Clinical Services, when shown the Treatment Modalities and Interventions, said that since she took over her position in October 2014, she had been having weekly meetings with the therapists. She said she had recognized the modalities were not individualized and so was giving the therapist ideas on how to individualize the plans. She was asked how she was monitoring the therapists' progress in individualizing the plans. She said she had just hired RN #104 as her assistant to help with training, monitoring and assisting therapist when they needed help. She said she was thinking about having the therapist use the patient's name in the plan in order to help them individualized the treatments.

Record review of the facility's Master treatment Plan/Reassessment reviewed on 7/12 revealed the following:
"Purpose:
1. To provide documentation in the patient record of the care and treatment in all inpatient services...that is planned and provided as interdisciplinary, collaborative manner by qualified individuals. To provide documentation in the patient record that the patient's progress is periodically evaluated against care goals and the plan of care, and when indicated, the plan or goals are revised....
10....Each discipline is to address the objectives that are to be met by the patient in their modality. The objectives must be measurable and observed. they are the individual steps for pursuing and achieving the long term goal. The frequency and the treatment method to be used to assist the patient in meeting the objective must be identified..."

Based on record review and interview, the facility failed to ensure the treatment plan included the name of the staff responsible for identified treatments and modalities for 10 of 31 patients reviewed (#'s 3, 4, 5, 6, 7, 8, 9, 12, 36 and 37).

This failure potentially results in the patient and other staff being unaware of which staff is assuming the responsibility for treatment of the patient, the intervention being implemented and documenting progress toward treatment goals.

Findings include:

Record review of the facility's Master Treatment Plan/Reassessment reviewed on 7/12 revealed the following:
"Purpose:
1. To provide documentation in the patient record of the care and treatment in all inpatient services...that is planned and provided as interdisciplinary, collaborative manner by qualified individuals. To provide documentation in the patient record that the patient's progress is periodically evaluated against care goals and the plan of care, and when indicated, the plan or goals are revised....
10....Each discipline is to address the objectives that are to be met by the patient in their modality. The objectives must be measurable and observed. They are the individual steps for pursuing and achieving the long term goal. The frequency and the treatment method to be used to assist the patient in meeting the objective must be identified and the responsible staff providing the modality must be identified by name."


Patient #3

Record review of Patient #3's Adult Multidisciplinary Treatment Plan, Psychosis, dated 12/4/14 under Treatment Modalities and Interventions for Clinical Services revealed it was blank.
Nursing Diagnosis: Risk for Violence - Self or Other Directed - "Encourage pt. (patient) to verbalize feelings and thoughts to staff. Ongoing and every shift.

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.


Patient #4

Record review of Patient #4's Adult Multidisciplinary Treatment Plan, Psychosis, dated 12/4/14 under Treatment Modalities and Interventions listed the following:
Psychiatry - the section was blank
Recreational Therapy - Recreational/leisure education therapy 3 to 5 times per week
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form
Clinical Services -
-Group therapy (GT) - pt. will engage in GT to increase knowledge and skills related to mental illness, including medication management and coping skills.
-Individual therapy (IT) - pt. will receive IT as needed to address individual needs and concerns.
-Family therapy (FT) - pt. will engage in at least one FT to facilitate positive communication and discuss discharge plans.

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #5

Record review of Patient #4's Adult Multidisciplinary Treatment Plan, Psychosis, dated 12/2/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - the section was blank
Recreational Therapy - Recreational/leisure education therapy 3 to 5 times per week
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form
Clinical Services
-Group therapy - pt. will engage in GT to increase knowledge and skills related to mental illness, including medication management
-Individual therapy - pt. will engage in IT to address individual needs and concerns
-Family therapy - pt. will engage in FT as needed to facilitate positive communication and discuss discharge plans.

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #6

Record review of Patient #6's Adult Multidisciplinary Treatment Plan, Psychosis, dated 11/10/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - the section was blank
Recreational Therapy - Recreational/leisure education therapy 3 to 5 times per week
Relaxation Therapy 1 to 2 times a week. These were preprinted on the form

Clinical Services
"IT= Discuss reasons for admission
FT = Discuss D/C (discharge) plan & relapse prevention
GT= Discuss triggers & coping mechanisms"

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #7

Record review of Patient #7's Adult Multidisciplinary Treatment Plan, Mood Disturbance for Depression and Anxiety, dated 11/23/14 under Treatment Modalities and Interventions listed the following:

Recreational Therapy - Recreational/leisure education therapy 4 times per week
Clinical Services
"IT= Discuss reasons for admission
FT = Discuss D/C (discharge) plan & relapse prevention
GT= Identify triggers & coping skills"

Nursing Diagnosis:
- Encourage verbalization of feelings or frustrations. Document and help pt. to develop adaptive coping skills relevant for managing mood shifts.
-Encourage group participation

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Record review of Patient #7's Adult Multidisciplinary Treatment Plan, Psychosis dated 11/23/14 under Treatment Modalities and Interventions listed the following:

Recreational Therapy - Reality Group 3 times a week.
Clinical Services
"IT= Identify reasons for admission
FT = Discuss D/C (discharge), relapse prevention
GT= Identify triggers and coping skills"

Nursing Diagnosis:

- Set limits with less restrictive actions and redirect pt.

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #8

Record review of Patient #7's Adult Multidisciplinary Treatment Plan, Mood Disturbance, dated 11/30/14, under Treatment Modalities and Interventions listed the following:

Psychiatry - was signed but nothing was added or addressed.
Recreational Therapy - Recreational/leisure education therapy 3 times per week
Reality Group 4 times a week.
Clinical Services
-Group therapy (GT) - GT to increase knowledge and skills related to mental illness
-Individual therapy (IT) - IT as needed to address individual needs and concerns.
-Family therapy (FT) - FT to facilitate positive communication with family and discuss discharge plans.

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #9

Record review of Patient #9's Adult Multidisciplinary Treatment Plan, Mood Disturbance for Depression and Anxiety, dated 11/26/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - was signed but nothing was added or addressed.
Recreational Therapy - Recreational/leisure education therapy 4 times per week
Social skills Group 3 times a week.
Clinical Services - Pt. will attend therapeutic group to learn new coping skills.
Pt. will attend IT sessions to discuss reasons for admission
Pt. will attend FT to discuss discharge plans.

Nursing Diagnosis -

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #12

Record review of Patient #12's Adult Multidisciplinary Treatment Plan, Mood Disturbance for Mania, dated 12/5/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - was signed but nothing was added or addressed.
Recreational Therapy - Recreational/leisure education therapy 4 times per week
Clinical Services - Pt. will have IT for assessment of symptoms and treatment planning
Pt. will attend group therapy for increased social functioning and coping skills for mania.
Pt. will have FT for discharge planning.
Nursing Diagnosis - Safety observations to keep patient safe from harm
Monitor for early S&S agitation/anger

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #36

Record review of Patient #36's Adult Multidisciplinary Treatment Plan, Psychosis dated 12/5/14 under Treatment Modalities and Interventions listed the following:

Psychiatry - was signed but nothing was added or addressed.
Recreational Therapy - Recreational/leisure education therapy 4 times per week
Social Skills Group
Clinical Services -
-Individual supportive counseling to help patient understand relationship between biopsychosocial stressors and onset of symptoms.
-Group Therapy to facilitate identification of strategies to decrease/minimize symptoms of psychosis
-Mulitfamily Group to educate family regarding signs, symptoms, coping strategies and community resources

Nursing Diagnosis:
-Safety observations
-Obtain written or oral contract to notify staff of thoughts/impulses to harm self or others
-Assess and document thoughts and behaviors of self-harm or harm to others
-Encourage patient to verbalize anger
-Monitor for signs of increased agitation and assist pt. in using coping strategies.
-Observe for early signs of increased agitation/irritability
-Set limits on violent/aggressive behaviors
-Provide positive reinforcements

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Patient #37

Record review of Patient #37's Youth Multidisciplinary Treatment Plan, Physical Aggression dated 12/6/14 under Modalities and Interventions listed the following:


Psychiatry - was signed but not dated and nothing was added or addressed.
Clinical Services -
-Pt. will have IT to identify coping skills to help reduce aggression.
-Pt. will have FT to increase communication at home and implement safety plan.
-Pt. will attend groups to practice pro-social skills and coping methods.

Nursing Diagnosis:
-Safety observations to ensure pt. not harm self or others
-Monitor for early signs of agitation, anger or aggression and assist pt. in using coping strategies.
-Pt. to verbalize thoughts and feeling to staff instead of acting out.

Recreational Therapy - Physical fitness

The treatment plan did not specifically address which staff were to be responsible for what modality or intervention.

Interview on 12/11/14 at 12:10 p.m. with RN #56, Director of Clinical Services, when shown the Treatment Modalities and Interventions did not name the staff person responsible for implementing the treatments as per regulations and the facility's policy and procedure, she said she guessed the facility could add another column where the person could be identified.

Based on observation, record review and interview, the facility failed to conduct scheduled patient recreational therapeutic activities on the units.

Findings:
On 12/10/2014 at 10:55 a.m. patients were observed pacing the floor and sitting in the day room without staffs' presence.

Review of the facility's unit #3 activities calendar provided by facility's staff, revealed documentation which indicated that patients were scheduled to have community group.

Interview with Mental Health Worker (#84) revealed she said she was assigned to conduct the community group meeting. She stated, "I just did not get in there. I was doing vital signs, lots of people were leaving and I got behind."

Interview on 12/10/2014 at 11:30 a.m. with the Unit's Charge Nurse. She said she was not aware that the scheduled patient community group was not done.

Review on 12/10/2014 11:35 a.m. of Unit 3's Group Progress Notes and Daily Summary for 18 patients on the unit, revealed printed and pre-signed signature of the therapist name was noted on the Patients' Group Progress notes for scheduled 2-3 p.m. process group. activity.

The Surveyor requested to speak to the therapist. Interview with the Director of Social Services revealed the Therapist, who had printed and signed her name on 18 patients' group Progress Notes for the 2:00 - 3:00 p.m. process session, was not in the facility, because she had an emergency and had to leave the facility.

Interview on 12/12/2014 at 8:55 a.m. with Registered Licensed Social Worker #79, she said she was instructed to pre-fill information on the Group Progress notes and that all information on the Group Progress notes are pre-filled in the mornings. She said she should not have pre-signed the documents.