HospitalInspections.org

Based on interview and document review, the hospital did not ensure a comprehensive treatment plan, which included nursing care, was maintained for 8 of 8 patients (P8, P9, P30, P1, P2, P5, P13, P14) whose care plans were reviewed.

Findings include:

Patient P8 was admitted to the psychiatric hospital on 4/14/15, according to the Minnesota State Operated Services Face Sheet. The Psychiatric Assessment data sheet, dated 4/15/15, indicated the patient had diagnoses which included schizo-affective disorder, bipolar type and poly-substance abuse. The assessment indicated the patient had attempted suicide in the past and had a history of violence toward self and others. The treatment and management plan identified on the psychiatric assessment included frequent observations given the history of suicide attempts and self-injury. The assessment also indicated the patient estimated he had attempted suicide 40 to 50 times since age eleven with methods ranging from hanging, running into traffic, cutting, stabbing, and "suicide by cop."

The Nursing Assessment, dated 4/15/15, identified the patient as an emergency admit to the hospital due to psychosis and non-compliance with medications. The patient stated he was admitted to the hospital to get chemical dependency treatment.

The Vulnerability Risk Reduction Plan/Initial Treatment Plan (VRRP), dated 4/15/15, and completed by a registered nurse (RN), identified a risk of self-harm due to self-injurious behaviors and attempts at suicide by hanging. The VRRP was updated to include patient incidents which included: punched/shattered window in dayroom (4/20/15), attempted self-harm by choking himself with a blanket (5/11/15), cutting at wrist (5/20/15), attempted to hang self while in jail (5/21/15), assaulted peer and cut forearm with broken glass (9/15/15), and suicide attempt by tying a shoelace around his neck (9/19/15). The VRRP also identified a risk of aggressive or predatory behavior toward peers which included both physical aggression as well as verbal aggression. The VRRP indicated the patient had made threatening remarks to staff, pulled a phone off the wall and cut his wrist on 5/20/15, and was taken to jail. Although the VRRP/Initial Treatment Plan included many nursing interventions, none of these were on the current Patient Treatment Plan, dated 10/20/15.

The Support Plan, dated 9/4/15, identified patient behaviors which included self-injurious behaviors and property destruction. The plan included coping skills the patient could use as well as precursors the patient exhibited prior to target behaviors. The support plan included interventions staff could use if the patient was showing the beginning of self-injurious behavior or property destruction. An emergency intervention procedure identified in the support plan included allowing the patient to sit in the restraint chair without the application of restraints with a weighted blanket on him and to inform the patient he could leave the restraint room at any time. Staff were directed to remain with the patient the entire time. Staff were directed to apply a restraint as a last resort if all other interventions had failed. None of these interventions or plans were included in the most recent Patient Treatment Plan and Report, dated 10/20/15.

Although the patient had cut his forearm with broken glass on 9/15/15, and had tied a shoe lace around his neck on 9/19/15, the most recent Patient Treatment Plan Report, last updated 10/20/15, no longer addressed a problem related to suicide ideation. Although interventions were used during attempts at self-harm such as close observation and 1:1 observation, these were not identified on the Patient Treatment Plan. Although nursing staff had identified coping mechanism and triggers which provoked aggressive behaviors and suicide ideation in the Vulnerability Risk Reduction Plan (VRRP) and the Support Plan, none of these were included in the Patient Treatment Plan.

Progress notes dated 9/15/15, 9/16/15, 9/17/15 and 10/20/15 indicated the patient was restrained in either the restraint chair or four point restraints. The Patient Treatment Plan, dated 10/20/15, did not address the use of restraints.

A review of the Patient Treatment Plan Report, last updated 9/22/15, identified a problem related to a history of suicide ideation and violence toward other staff and himself. The goal included the patient working with the treatment team to lessen/eliminate impulsive behaviors, including harming himself and aggression toward peers and staff. Although the patient continued to have evidence of suicide attempts and violence to self and others, the status of the goal was identified as "not met but ended" and the date the goal was met, according to the treatment plan, was 9/18/15.


P9 was admitted to the psychiatric hospital on 8/7/15, according to the Minnesota State Operated Services Face Sheet.

The Nursing Assessment, completed 8/7/15, indicated the patient had a history of self-injurious behavior and suicidal thoughts. The patient also had reported a past history of swallowing a razor blade five months earlier. The initial care plan, dated 8/7/15, revealed medical records had indicated the patient reported she would injure herself if left alone and she had followed that with a suicide attempt two weeks earlier. The patient identified triggers to psychiatric symptoms as yelling and screaming, patients fighting and the recent death of her aunt and cousin. The patient identified signs which could indicate she may be stressed as beginning to isolate herself and unwillingness to talk to anyone. The initial care plan indicated the patient would be on frequent observations until further assessment could be completed.

The Psychiatric Assessment, dated 8/7/15, indicated the patient had diagnoses which included a recent suicide attempt by ingesting multiple medications, impulse control disorder, depression and post-traumatic stress disorder.

Although the Vulnerability Risk Reduction Plan (VRRP)/Initial Treatment Plan, completed by nursing and dated 8/7/15, had been updated by nursing to include a suicide attempt since admission and incidents of aggression toward staff and peers, none of this information was included in the Patient Treatment Plan. Although the patient had identified coping skills and staff interventions which could be used to prevent harming herself as well as triggers which provoked aggression, none of these were included in the Patient Treatment Plan. Interventions on the Patient Treatment Plan were generic and were normal functions of the professional disciplines involved in the patient's care and were not individualized to the patient.

P30 was admitted to the psychiatric hospital on 10/1/15, according to the Minnesota State Operated Services Face Sheet.

The admission Psychiatric Assessment, dated 10/2/15, indicated the patient had diagnoses which included bipolar disorder (severe with psychotic features), schizo-affective disorder and alcohol use disorder. The patient also experienced auditory hallucinations. The patient was admitted due to medication non-compliance and making terroristic threats.

The Patient Treatment Plan Report, dated 10/21/15, contained generic interventions for all disciplines, including nursing, which were normal functions of the professional disciplines and not individualized to the patient. One objective on the plan was to identify behaviors that interfered with the patient's daily living. Nursing interventions were to monitor the effectiveness of medications and manage side effects and to meet with the patient daily to identify behaviors which interfered with his daily living as evidenced by documentation.

P1 was admitted to the psychiatric hospital on dated 9/23/15, according to the Minnesota State Operated Services Face Sheet.

The Minnesota State Operated Services Face Sheet dated 9/23/15, described P1 as being admitted to a state facility due to aggression and severe property damage, with medical diagnoses that included diabetes, hypertension, asthma, and chronic low back pain.

The current Minnesota Department of Human Services State Operated Services