HospitalInspections.org

30524

30524

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

I. Adequately assess and treat the identified special needs patient currently in the facility (B3). Specifically the facility failed to:

A. Develop and document social service assessments for 1 of 9 active sample patients (B3). As a result the treatment team did not have critical information to develop a treatment plan as to how to communicate with a special needs patient with an identified hearing loss. (Refer to B 108)

B. Develop and document master treatment plans utilizing special treatment modalities that clearly address the special needs of 1 of 9 active sample patients (B3). Specifically, the facility failed to develop and document a treatment plan for a patient (B3) with identified hearing loss and an effective means for the staff to communicate with the patient and to engage the patient in treatment. This failure results in lack of guidance for staff in providing individualized treatment that is purposeful and goal directed. (Refer to B 122)

C. Develop and document active therapeutic efforts for 1 of 9 active sample patients (B3) with identified special need of a documented 80% hearing loss. This failure results in a delay in treatment, a lack of engagement in active treatment and the potential for ineffective communication regarding treatment issues and/or concerns including a failure to provide for special needs. (Refer to B 125)

D. Ensure that nurses regularly recorded in progress notes interventions utilized and their effectiveness in communicating with 1 of 9 active sample patients (B3) with special needs. Instead the progress notes were generic and indicated the patient was refusing treatment. This failure results in the patient not having a coordinated plan for how to have their needs met and therefore was not receiving active treatment. (Refer to B 127)

E. Ensure that social workers regularly recorded in progress notes collateral information obtained from family members regarding the extent of hearing loss and necessary interventions for communicating with 1 of 9 active sample patients (B3) with special needs. Instead the progress notes were generic and lacked specificity as to how to communicate with this special needs patient. This failure results in the patient not having a coordinated plan for how to have their needs met and therefore was not receiving active treatment. (Refer to B 128)

II. In addition, the facility failed to document the date and time of follow-up appointments in the discharge summaries of 3 of 5 discharge records reviewed (D2, D3, and D4). The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices, which they find difficult to do, and therefore may fail to do. (Refer to B134)

Based on record review, policy review and staff interviews, the facility failed to ensure that the social service assessment was completed for 1 of 9 active sample patients (B3). This results in the treatment team not having current baseline social functioning for establishing treatment goals and interventions.

Findings include:

A. Record Review

1. Patient B3 was admitted on 10/19/12. The Psychiatric Evaluation dated 10/20/2012 stated the patient was "taken by [his/her] brother to the crisis center of Detroit Receiving Hospital. Brother petitioned [him/her] stating that the patient was walking around naked, walking all night. Not sleeping. [S/he] is not taking [his/her] medications for at least a month. Records from DMC indicate that the patient declined to give information. [S/he] is unable to take care of [his/her] personal hygiene. [S/he] has poor insight and judgment. [S/he] refused to talk."
"Axis I: Schizophrenia paranoid type rule out schizoaffective disorder
Axis II: Deferred
Axis III: None"
2. On 10/20/12, the social worker documented on the psychosocial assessment, "unable to obtain" on all areas of the form. In the section, labeled "Barriers to Learning" an "x" was in the block preceding hearing. The first statement of the section titled "Clinical Summary" stated "patient deaf or very hard of hearing." The clinical summary and the initial progress note written by the social worker failed to document whether there were attempts made to contact the brother or other family member to identify effective means of communicating with this patient who has an identified hearing loss.

B. Policy Review

Facility Policy "Psychosocial Assessments," dated 09/7/12, in the section titled "Initial Assessment" states "the psychosocial assessment should include but is not limited to the following," #8 specifically states "to assess patient's available social and/or family contacts that can be made to attain additional history, discharge planning and family involvement either through phone contact and or family meetings."

C. Staff Interviews

1. During an interview with the Director of Social Work on 10/22/12 at 02:20 p.m., she stated "in my mind, the social worker really dropped the ball on this one. The social worker, if they did not know what to do with this situation, should have asked. I was actually here for part of the day on Saturday and was not made aware of any issues. I believe at the least the social worker should have tried to make phone calls to the brother or other family member to determine what type of hearing loss [Patient B3] has and what would be the most effective way for us to communicate with the patient while on our unit." During this same interview it was determined that the social worker who had completed the psychosocial assessment on Patient B3 was a contingent (casual) employee. When specifically asked what training the contingent staff have had related to the expectations for timely and comprehensive data collection on the assessment, the Director of Social Work stated "there has not been a formal plan put in place; when we re-trained all of our social workers on the role of social work and psychosocial assessments the re-training was only done with the full time staff."

2. During an interview with Social Worker #1, on 10/23/12 at 12:00 p.m., the social worker reported that there was a phone conversation with the Patient B3's brother at around 03:00 p.m. the prior day at which time the patient's brother reported that "the patient has an 80% hearing loss, does not speak but can read and write, did graduate from high school." The patient's brother also reported "if you want to get [the patient's] attention, you need to look at [the patient] directly because [the patient] can read lips. [The patient] does not know sign language and does not wear any hearing aids; [the patient] stopped wearing aids about a year or so ago." When asked if the plan of care for this patient had been changed given that this information had become available, the social worker stated "Yes. I started it yesterday after talking with the brother." At 01:20 p.m. on 10/23/12 the surveyor requested a copy of the updated treatment plan addressing the plan for effective communication with Patient B3; there were no updates made to the plan. Social Worker #1 stated "I have not had a chance to write it yet; I had a follow-up call today with the patient's brother and mother and I need to write an addendum to the treatment plan."






25352

Based on record review and staff interview, it was determined that the facility failed to insure that the medical record included specific information of chronic non-psychiatric disorders in the medical record of 1 of 9 active sample patients (B3). This resulted in failure to take into account the patient's medical need and to assess the impact of a chronic medical condition on current psychiatric presentation.

Findings include:

A. Record Review

Patient B3 was admitted on 10/19/2012. The Psychiatric Evaluation dictated on 10/20/2012 at 07:57 p.m. stated the patient was "taken by [his/her] brother to the crisis center of Detroit Receiving Hospital. Brother petitioned [him/her] stating that the patient was walking around naked, walking all night. Not sleeping. [S/he] is not taking [his/her] medications for at least a month. Records from DMC indicate that the patient declined to give information. [S/he] is unable to take care of [his/her] personal hygiene. [S/he] has poor insight and judgment. [S/he] refused to talk."

"Axis I: Schizophrenia paranoid type rule out schizoaffective disorder

Axis II: Deferred

Axis III: None"

The psychiatric evaluation dated 10/20/2012 did not include a medical history of hearing loss and the Axis III diagnosis (where medical diagnoses are listed) indicated "None." An initial admission intake assessment done by the intake worker completed on 10/19/2012 at 02:57 p.m. had identified a history of hearing loss. A social work/psychosocial assessment completed on 10/20/2012 at 04:00 p.m. indicated "pt. deaf or very hard of hearing."

B. Staff Interview

During an interview on 10/23/2012 at 09:30 a.m., the Director of Nursing stated, "I understand it is not included in the psychiatric evaluation. I understand it is a serious issue. Social worker dropped the ball and did not communicate the issue with the rest of the team. The physician was not aware of the patient's (referring to patient B3) hearing impairment."

During an interview on 10/23/2012 at 11:20 a.m., the Director of Social Service stated, "I am very disappointed our social worker dropped the ball. I would have asked her to see the family member. [Patient B3] is a high school graduate. [S/he] used to wear hearing aids. That was a very badly managed issue."

During an interview on 10/23/2012 at 12:15 p.m., the Medical Director stated, "I agree with you hearing loss is not documented in the medical history. I agree collateral information should have been obtained but this is a chronic and very difficult patient (B3)."

Based on record review and staff interview, it was determined that the facility failed to perform and document an estimate of intellectual functioning and an estimate of memory functioning in the psychiatric evaluation of 1 of 9 active sample patients (B4). The failure can result in lack of identification of pathology which may be pertinent to the current mental illness, and it compromises future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

Patient B4 was admitted on 10/05/2012. The psychiatric evaluation completed on 10/05/2012 did not document an estimate of intellectual functioning and an estimate of memory functioning.

B. Staff Interview

During an interview on 10/23/2012 at 12:15 p.m., the Medical Director stated, "As a part of our corrective action plan we have a template to follow when we do psychiatric evaluations. Sometimes my medical staff does not follow that template...I agree with you that an estimate of memory functioning and intellectual functioning (for patient B4) are missing."

Based on record review and staff interview, it was determined that the facility failed to document an inventory of assets in the psychiatric evaluation of 1 of 9 active sample patients (B4). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.


Findings include:

A. Record Review

Patient B4 was admitted on 10/05/2012.

The psychiatric evaluation dated 10/5/2012 did not document an inventory of assets.


B. Staff Interview


During an interview on 10/23/2012 at 12:15 p.m., the Medical Director stated, "I agree with you that patient assets are missing."

Based on record review, interview and document review the facility failed to develop treatment plans for 1 of 9 active sample patients (B3) that clearly delineated interventions to address a specific problem. Specifically, the facility failed to develop and document a treatment plan on Patient B3 for identified hearing loss and an effective means for the staff to communicate with the patient and to engage the patient in treatment. This failure resulted in a lack of coordination of care, and the necessary staff interventions to assist the patient in meeting his individualized goals for active treatment.

Findings Include:

A. Record Review

1. Master Treatment Plan, which was completed in team meeting on the morning of 10/22/12 and received by the surveyor on 10/22/12 at 12:00 p.m. for Patient B3 (who was admitted 10/19/12), had nothing identified in the Axis III section. Additionally, the section titled "active medical problems" was left blank, and there was no treatment plan problem sheet to address the medical problem "hearing loss" that was identified on the intake information completed at the time of the referral for admission; on the nursing assessment completed on 10/19/12 at 08:00 p.m. which states "patient is hearing impaired, unable to communicate effectively through conversation. Assessment completed using non-verbal communication and writing down questions"; and on the psychosocial assessment done on 10/20/12 at 04:00 p.m. which states "patient deaf or very hard of hearing."

B. Interview

During an interview with the Director of Nursing, on 10/22/12 at 02:00 p.m., she reviewed the record for Patient B3, and verified that there was nothing included on the Master Treatment Plan to address the problem of hearing loss and communication needs. "As you can see I did add this to the nursing flow sheet because I am aware of the issues, and yes there should be a care plan that addresses the issue. I know this is a concern. Nursing should have at least initiated a care plan until additional information was available about the patient's hearing loss. The social worker should have further explored to determine the extent of the patient's hearing loss and communicated that with the entire team." In a follow up interview with the Director of Nursing on 10/24/12, at 9:45 AM, after the medical record for Patient B3 was re-reviewed for critical updates to the plan related to interventions for effective communication, the Director of Nursing stated "a nursing care plan has not been written and no specific updates to the treatment plan have been made by nursing. The specific nursing interventions that have been implemented should have been written yesterday after we found out the extent of hearing loss the patient specifically had. There was no reason for the nursing staff to wait for the entire team to meet. I have nursing adding those interventions to the treatment plan now."

C. Document Review

Facility policy, titled "Plan of Access to Care-General Accessibility," dated 08/22/12, section C states "if impairments are readily identifiable....nursing staff will access to determine the proper form of accommodation to enable the patient to best utilize the services provided. Nursing will note impairment on the patient's chart and the preferred accommodation."

Based on observation, interview and record review, the facility failed to adequately assess 1 of 1 active sample patients with special needs, Patient (B3), who has a documented 80% hearing loss. This failure results in a delay in treatment, a lack of engagement in active treatment and the potential for ineffective communication regarding treatment issues and/or concerns.

Findings include:

A. Record Review

1. The Psychiatric Evaluation dated 10/20/2012 stated the patient was "taken by [his/her] brother to the crisis center of Detroit Receiving Hospital. Brother petitioned [him/her] stating that the patient was walking around naked, walking all night. Not sleeping. [S/he] is not taking [his/her] medications for at least a month. Records from DMC indicate that the patient declined to give information. [S/he] is unable to take care of [his/her] personal hygiene. [S/he] has poor insight and judgment. [S/he] refused to talk."

"Axis I: Schizophrenia paranoid type rule out schizoaffective disorder

Axis II: Deferred

Axis III: None"

2. Nursing progress note written 10/20/12 at 11:00 a.m. states "patient isolative in room, patient bizarre, confused, observed walking into other patients' room. Patient was redirected and asked a question but does not respond. No groups attended. No interaction with peers or staff. Will encourage patient to attend groups and interact more with staff and peers and vent any uneasy feelings with staff." There is no evidence documented that the nursing staff intervened in ways other than through verbal interaction.

3. Nursing progress note written 10/20/12 at 9:15 p.m. states "isolative throughout shift, observed pacing in halls but no interaction with others." There was no evidence documented that the nursing staff attempted to communicate with the patient.

4. Nursing progress note written 10/21/12 at 1:15 p.m. states "no communication with staff or peers, patient does not respond to questions." No evidence documented that nursing staff attempted to communicate via means other than verbal communication.

5. Patient Teaching Record completed by nursing for 10/20/12 "making needs known;" 10/21/12 "daily hygiene;" 10/22/12 "coping skills;" and 10/23/12 "daily hygiene" all state patient was "non-receptive to learning readiness." The teaching method for each of these topics checked was "auditory" despite the fact that the learning barrier identified was "impaired hearing and language barrier."

B. Observation

The surveyor was on Unit B, on the following dates and times: 10/22/12 at 10:42 a.m.-12:20 p.m.; 10/22/12 at 2:00 p.m. to 3:00 p.m.; 10/23/12 at 9:30 a.m.-11:00 a.m. During these times Patient B3 remained in his/her bedroom, did not attend any scheduled groups and no observations of staff interactions with the patient were made, other than observing the staff member that was responsible for walking in the halls to complete every 15 minute observations. On 10/22/12, at 12:05 p.m., RN1 and MD1, accompanied by the surveyor, went into the patient's room to assess the patient's level of hearing impairment. MD1 had told the surveyor earlier in an interview that he did not believe the patient had a true hearing disorder but was "selectively mute as a manifestation of the patient's schizophrenia." The patient did not acknowledge the physician's knock on the door; upon entry into the patient's room, the patient was found lying awake in bed looking toward the ceiling. MD1 called the patient's name but got no response. At that time, MD1 sat on the edge of the patient's bed and began to speak with Patient B3. MD1 got no response from Patient B3. MD1 wrote questions on a paper to which patient B3 nodded his/her head as a response. MD1, in an attempt to demonstrate that patient B3 was selective in his/her interactions, stated to the patient "is this your money on the floor," and pointed to the floor next to the bed. The patient did not acknowledge or look toward the floor. MD1 repeated the question, to which again there was no response or acknowledgement. On the third attempt, MD1 bent over and pretended to pick something off the floor and place it in his pocket to which again the patient did not respond.

C. Interview

1. On 10/22/12 at 10:40 a.m., the surveyor asked the Nurse Manager to point out Patient B3, who had been identified as being deaf or having a hearing loss. The Nurse Manager stated "I am not aware of any patient that has been identified as being deaf or having a hearing loss." The surveyor showed the Nurse Manager the copy of the census report given to the surveyor, by the COO (Chief Operating Officer) at 9:00 a.m. with a note written stating "completely deaf right ear, partial left ear, reads lips." The surveyor and the Nurse Manager spoke with RN1, charge nurse on Unit B, to verify this information and RN1 stated "I am not aware that [s/he] is deaf or hard of hearing, I think the doctor has referred to the patient as being selectively mute because of the Schizophrenia."

2. On 10/22/12 at 11:50 AM, MD1 was interviewed about Patient B3, during which time MD1 stated that he did not believe patient B3 had a hearing loss but "does not respond to questions and is selectively mute as a manifestation of the Schizophrenia." In reviewing the record together, the surveyor pointed to the area on the intake assessment (which is the form that is sent to the unit prior to admission on a new referral) Axis III stated, "hearing- loss-no hearing aid." MD1 stated "I was not aware of this Axis III diagnosis." MD1 stated, "I know if this is true then this will change our way of treating the patient." MD1 attempted to contact the patient's brother who was the person who initiated the petition for hospitalization to clarify this issue of the hearing loss but was not successful in making contact. MD1 paged Social Worker #1 and asked that Social Worker #1 make contact with the patient ' s family to determine the level of hearing impairment and needs for communication.

3. During an interview with Social Worker #1, on 10/23/12 at 12:00 p.m., the social worker reported that there was a phone conversation with Patient B3's brother around 03:00 p.m. the prior day, at which time the patient's brother reported that "[the patient] has an 80% hearing loss, does not speak but can read and write, did graduate from high school." The brother also reported "if you want to get [the patient ' s] attention, you need to look at [the patient] directly because [the patient] can read lips. [The patient] does not know sign language and does not wear any hearing aids. When asked if the plan of care for this patient had been changed given that this information had become available the social worker stated "yes. I started it yesterday after talking with the brother." At 01:20 p.m. on 10/23/12 the surveyor requested a copy of the updated treatment plan addressing the plan for effective communication with patient B3, there were no updates made to the plan. Social Worker #1 stated "I have not had a chance to write it yet, I had a follow up call today with the patients' brother and mother and I need to write an addendum to the treatment plan." This phone conversation with the patients' brother occurred on 10/22/12 as noted in the patients' record as dictated by the social worker on 10/22/12 at 04:02 p.m.

4. On 10/23/12 at 01:30 p.m., the surveyor went into the patient's room to determine if Patient B3 had been given any materials for writing notes as a means of communicating with staff, given that the patient's brother had communicated in an earlier phone call with Social Worker #1 that the patient either reads lips or can read and write notes. As of that time nothing had been provided to the patient. State surveyors also reported that when they were in the patient's room at 03:45 p.m. they needed to ask staff for paper and pencil so they could interview the patient. On 10/24/12 at 9:20 a.m., the surveyor again assessed whether or not any materials for writing notes to staff had been given to the patient; there was one piece of a 3x5 piece of paper and a small pencil lying on the patient's nightstand. This piece of paper was filled with small blocks that someone had drawn. There was no other paper in the room for the patient to use for writing. RN2 was then questioned as to what plans had been put in place and communicated to the other team members as to how to effectively communicate with Patient B3. RN2 stated "the same as yesterday, we are writing things out for the patient." RN2 stated "we bring paper into the room with us when we go in to talk with the patient." The surveyor asked RN2 if this is written in the record somewhere so that all staff were aware and RN2 stated "no, I have not written anything yet."

5. An interview with Mental Health Technician (MHT)1 was done on 10/24/12 at 9:35 AM at which time the surveyor asked the MHT if there had been a specific plan that was communicated to staff as to how to communicate with Patient B3. MHT1 stated, "No, I know only a few words in sign language and the patient seems to understand those. I have used hand gestures when trying to get my point across and I think the patient can read lips."

6. During the interview with the Director of Nursing on 10/24/12 at 9:45 AM she stated "I have reviewed the (nursing) progress notes on [Patient B3] and I agree that the documentation does not demonstrate that nursing has put anything in place to communicate with this patient. They (the notes) are all generic and make it look like the patient is refusing treatment, when we do not know if the patient really understands."

Based on record review and interview, the facility failed to ensure that nurses regularly recorded in progress notes interventions utilized and their effectiveness in communicating with 1 of 1 active sample patient with special needs (Patient B3). Instead the progress notes were generic and indicated the patient was refusing treatment. This failure results in the patient not having a coordinated plan for how to have his/her needs met, and therefore not receiving active treatment.

A. Record Review

1. Nursing progress note written 10/20/12 at 11:00 a.m. states "patient isolative in room, patient bizarre, confused, observed walking into other patients' room. Patient was redirected and asked a question but does not respond. No groups attended. No interaction with peers or staff. Will encourage patient to attend groups and interact more with staff and peers and vent any uneasy feelings with staff." There is no evidence documented that the nursing staff intervened in ways other than through verbal interaction.

2. Nursing progress note written 10/20/12 at 9:15 p.m. states "isolative throughout shift, observed pacing in halls but no interaction with others." There is no evidence documented that the nursing staff attempted to communicate with the patient.

3. Nursing progress note written 10/21/12 at 1:15 p.m. states "no communication with staff or peers, patient does not respond to questions." No evidence documented that nursing staff attempted to communicate via means other than verbal communication.

4. Patient Teaching Record completed by nursing for 10/20/12 "making needs known;" 10/21/12 "daily hygiene;" 10/22/12 "coping skills;" and 10/23/12 "daily hygiene" all state patient was "non-receptive to learning readiness." The teaching method for each of these topics checked was "auditory" despite the fact that the learning barrier identified was "impaired hearing and language barrier."

5. Patient B3's Medication Administration Records had documentation that all medications (Haldol, Cogentin, Ativan and Trileptal, ordered for 3:00 p.m. on 10/20/12 and scheduled for 9:00 a.m. and 3:00 p.m. on 10/21/12) were refused by the patient. There was no evidence that means other than verbal communication was utilized by nursing staff to educate patient on the use of the medications ordered.

B. Interview

During the interview with the Director of Nursing on 10/24/12 at 9:45 AM she stated "I have reviewed the progress notes on [Patient B3] and I agree that the documentation does not demonstrate that nursing has put anything in place to communicate with this patient. They (the notes) are all generic and make it look like the patient is refusing treatment, when we do not know if the patient really understands."

Based on record review and interview, the facility failed to ensure that social workers regularly recorded in progress notes collateral information obtained from family members regarding the extent of hearing loss and necessary interventions for communicating with 1 of 1 active sample patients with special needs (Patient B3). Instead the progress notes were generic and lacked specificity as to how to communicate with this special needs patient. This failure results in the patient not having a coordinated plan for how to have his/her needs met and therefore not receiving active treatment.

A. Record Review

1. Psychosocial Assessment for Patient B3 completed on 10/20/12 at 4:00 PM, in the section titled "Social Work Interventions," had listed "provide 60-90 minute group therapy daily," despite that the clinical summary section stated in the first sentence "patient deaf or very hard of hearing." The initial progress note written by the same social worker did not reflect that the social worker attempted to contact the patient's brother, who was the petitioner on the commitment or other family member, to obtain additional information related to the patient's hearing loss.

B. During an interview with Social Worker #1, on 10/23/12 at 12:00 p.m. the social worker reported that the only information received from the contingent social worker, who had attempted to complete the psychosocial assessment on Patient B3 over the weekend, was that "they were not able to complete. There were no specific concerns passed on, that the patient had a hearing loss or that we needed to find out how to communicate with the patient. This did not come up until after you (the surveyor) talked to the patient's psychiatrist yesterday."

Based on record review and staff interview, it was determined that the facility failed to ensure that follow-up appointments were included in the discharge summaries for 3 of 5 patients (D2, D3, and D4) whose discharge records were reviewed. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do.

Findings include:

A. Record Review

1. Patient D2 was discharged on 9/7/2012. Discharge summary dictated on 9/29/2012 did not include the date and time for follow-up appointments.

2. Patient D3 was discharged on 9/10/2012. Discharge summary dictated on 9/27/2012 did not include the date and time for follow-up appointments.

3. Patient D4 was discharged on 9/11/2012. Discharge summary dictated on 9/29/2012 did not include the date and time for follow-up appointments.


B. Staff Interview

During an interview on 10/23/2012 at 12:10 p.m., the Medical Director stated, "I know that is still a problem. I have sent a memo out to the medical staff. We are monitoring the issue."

Based on record review, policy review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. The Medical Director failed to assure that:

I. A social service assessment was completed for 1 of 9 active sample patients (B3). This failure results in the treatment team not having current baseline social functioning to establish treatment goals and interventions. (Refer to B108)

II. Physicians performed and documented an estimate of intellectual functioning and an estimate of memory functioning in the psychiatric evaluation of 1 of 9 active sample patients (B4). Failure to document specific testing can lead to failure to identify pathology which may be pertinent to the current mental illness, and it compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

III. Physicians documented an inventory of assets in the psychiatric evaluation of 1 of 9 active sample patients (B4). Failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)

IV. The treatment plans of 1 of 9 active sample patients (B3) identified clearly delineated interventions to address specific problems. This failure results in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed. (Refer to B122)

V. Develop and document active therapeutic efforts for 1 of 9 active sample patients (B3) with identified special need of a documented 80% hearing loss. This failure results in a delay in treatment, a lack of engagement in active treatment and the potential for ineffective communication regarding treatment issues and/or concerns including a failure to provide for special needs. (Refer to B125)

VI. The follow-up appointments were included in the discharge summaries for 3 of 5 patients (D2, D3, and D4) whose discharge records were reviewed. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do. (Refer to B134)

Based on record review, observation and interview, the Director of Nursing failed to ensure that nursing staff followed acceptable standards of practice for assessment, intervention and plan of care for 1 of 1 active sample patients with special needs (Patient B3). This failure results in the patient not receiving active treatment and not having his/her personal needs met.

A. Record Review

1. Nursing progress note written 10/20/12 at 11:00 a.m. states "patient isolative in room, patient bizarre, confused, observed walking into other patients' room. Patient was redirected and asked a question but does not respond. No groups attended. No interaction with peers or staff. Will encourage patient to attend groups and interact more with staff and peers and vent any uneasy feelings with staff." There is no evidence documented that the nursing staff intervened in ways other than through verbal interaction.

2. Nursing progress note written 10/20/12 at 9:15 p.m. states "isolative throughout shift, observed pacing in halls but no interaction with others." There is no evidence documented that the nursing staff attempted to communicate with the patient.

3. Nursing progress note written 10/21/12 at 1:15 p.m. states "no communication with staff or peers, patient does not respond to questions." No evidence documented that nursing staff attempted to communicate via means other than verbal communication.

4. Patient Teaching Record completed by nursing for 10/20/12 "making needs known," 10/21/12 "daily hygiene," 10/22/12 "coping skills," and 10/23/12 "daily hygiene" all state patient was "non-receptive to learning readiness." The teaching method for each of these topics checked was "auditory" despite the fact that the learning barrier identified was "impaired hearing and language barrier."

5. Patient B3's Medication Administration Records had documentation that all medications (Haldol, Cogentin, Ativan and Trileptal ordered for 03:00 p.m. on 10/20/12 and scheduled for 09:00 a.m. and 03:00 p.m.) were refused by the patient. There was no evidence that means other than verbal communication was utilized by nursing staff to educate patient on the use of the medications ordered.

B. Observation

The surveyor was on Unit B on the following dates and times: 10/22/12 at 10:42 a.m.-12:20 p.m.; 10/22/12 at 2:00 p.m. to 3:00 p.m.; 10/23/12 at 9:30 a.m.-11:00a.m. During those times Patient B3 remained in his/her bedroom, did not attend any scheduled groups and no observations of staff interactions with the patient were made, other than observing the staff member that was responsible for walking in the halls to complete every 15 minute observations.

C. Interview

During an interview with the Director of Nursing, on 10/22/12 at 2:00 p.m., she reviewed the record for Patient B3, and verified that there was nothing included on the Master Treatment Plan to address the problem of hearing loss and communication needs. "As you can see I did add this to the nursing flow sheet because I am aware of the issues, and yes there should be a care plan that addresses the issue. I know this is a concern. Nursing should have at least initiated a care plan until additional information was available about the patient's hearing loss." In a follow up interview with the Director of Nursing on 10/24/12, at 9:45 a.m., after the medical record for Patient B3 was re-reviewed for critical updates to the plan related to interventions for effective communication, the Director of Nursing stated "a nursing care plan has not been written and no specific updates to the treatment plan have been made by nursing. The specific nursing interventions that have been implemented should have been written yesterday after we found out the extent of hearing loss the patient specifically had. There was no reason for the nursing staff to wait for the entire team to meet. I will have nursing add those interventions to the treatment plan now." During this same interview with the Director of Nursing on 10/24/12 at 9:45 a.m. she stated "I have reviewed the progress notes on [Patient B3] and I agree that the documentation does not demonstrate that nursing has put anything in place to communicate with this patient. They (the notes) are all generic and make it look like the patient is refusing treatment, when we do not know if the patient does understand."

Based on record review and interview the Director of Social Work failed to: 1. monitor and evaluate the quality and appropriateness of social services and 2. ensure that social work assessments met professional social work standards. These failures resulted in a lack of professional social work treatment services and the failure of the treatment team to identify and address important treatment issues for 1 of 1 active sample patients, with special needs (Patient B3).

Findings include:

A. Record Review

1. Patient B3 was admitted on 10/19/12. On 10/20/12, the social worker documented on the psychosocial assessment, "unable to obtain" on all areas of the form. In the section, labeled "Barriers to Learning" an "x" was in the block preceding hearing. The first statement of the section titled "Clinical Summary" stated "patient deaf or very hard of hearing." This clinical summary completed by the social worker, and the initial progress note written by the social worker, failed to include documentation whether there were attempts made to contact the brother or other family member to identify an effective means of communicating with the patient.

2. The employee sign-off verification for completion of Social work training on the Social Work Assessment/Re-assessment Policy completed 9/13/12 had 5 signatures present. The Director of Nursing reviewed these signatures with the surveyor on 10/22/12 at 2:20 PM and stated "they are the signatures of the full time staff; a plan has not been put into place for the contingent social work staff." The Director of Nursing and the Director of Social Work reviewed the psychosocial assessment for Patient B3, completed on 10/22/12, and determined that the social worker who completed the assessment was a contingent social worker.

B. Interview

During an interview with the Director of Social Work, in the presence of the Director of Nursing, on 10/22/12 at 2:20 PM, she stated "in my mind, the social worker really dropped the ball on this one. The social worker, if they did not know what to do with this situation, should have asked. I was actually here for part of the day on Saturday and was not made aware of any issues. I believe at the least the social worker should have tried to make phone calls to the brother or other family member to determine what type of hearing loss [Patient B3] has and what would be the most effective way for us to communicate with the patient while on our unit." During this same interview it had been determined that the social worker who had completed the psychosocial assessment on patient B3 was a contingent (casual) employee. When the Director of Social Work was specifically asked what training the contingent staff have had related to the expectations for timely and comprehensive data collection on the assessment the statement made was "there has not been a formal plan put in place, when we re-trained all of our social workers the re-training was only done with the full time staff."

C. Policy Review

Facility Policy "Psychosocial Assessments," dated 9/7/12, in the section titled "Initial Assessment" states "the psychosocial assessment should include but is not limited to the following," #8 specifically states "to assess patient's available social and/or family contacts that can be made to attain additional history, discharge planning and family involvement either or through phone contact and or family meetings."