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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 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 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."