HospitalInspections.org

Based on record review and interview, the facility failed to provide a treatment plan that delineated short term patient centered goals based on individual needs and/or problem behaviors requiring hospitalization for five (5) of five (5) sample patients (A1, A2, A3, A4 and A5). Many of the short term goals were not consistently described in observable, measurable, and behavioral terms. Others were staff goals (What the staff wanted the patient to accomplish) and not patient goals (What behaviors the patient wanted and/ or needed to accomplish to move toward discharge). These failures hinder the ability of the team to measure change in the patient as a result of treatment interventions and may prolong hospital stays beyond the resolution of the behaviors requiring admission.

Findings include:

A. Record Review

1. Patient A1, Master Treatment Plan dated 4/4/16, had the following short term goals for the identified problem "Defensive coping":

a. "Remain safe with the aid of medication and nursing interventions (either interpersonal, chemical, or seclusion), as will others in the client's environment throughout IPU [Inpatient Unit] stay."

b. "Focus on reality based activity with the aid of medication/nursing/family support and community mental health care by 1 day prior to dc [discharge]."

These goals were not specific to the individual patient and described routine, generic staff functions.

2. Patient A2, Master Treatment Plan dated 4/13/16, had the following short term goals for the identified problem, "Ineffective individual coping":

a. "Complete safety plan and sobriety plan within 2 days of admission."

b. "Stay safe while on IPU [Inpatient Unit]."

These goals were staff goals.

3. Patient A3, Master Treatment Plan dated 3/1/16, had the following short term goals for the identified problem "Potential for violence toward others r/t [related to] delusions of others harming his family":

a. "By one day prior to d/c [discharge] remain safe on IPU [Inpatient Unit."

b. "Talk at [sic] concrete happenings in the environment for 5 min [minutes] without [sic] talking at delusions."

c. "Contract for safety q [every] shift and prn [as needed]."

d. "Begin to recognize that suspicious thinking occurs at times of stress and anxiety."

e. "Learn 2 positive [sic] coping skills."

f. "Complete safety plan."

Goals b, d, and e were not measurable. Goals a, c, and f were staff goals.

4. Patient A4, Master Treatment Plan dated 4/12/16, had the following short term goals for the identified problem "Potential for self-harm":

a. "One day prior to d/c [discharge] remain safe on IPU [Inpatient Unit]."

b. "Attend 75% of groups."

c. "Complete safety plan."

These were staff goals. Goal "a" also did not describe how the patient was to remain safe on the unit.

5. Patient A5,Master Treatment Plan dated 3/17/16, had the following short term goals for the identified problem "Alterations in sensorium and [sic] mood r/t [related to] symptom exacerbation of bipolar illness [manic phase]":

a. "Respond with [sic] [decreased] symptoms [sic] from agreed tx [treatment] from him/her psychiatrist by 3-24-16."

b. "Have no bizarre behaviors by 3-20-16. Demonstrate decrease [sic] in manic sx's [symptoms] by 3-20-16."

c. "Take medications as prescribed daily and prn [as needed]. Providing [sic] for teaching needs prn [as needed]."


Goals a and b were not specific to the individual patient and were not measurable. "c" was a staff goal.

B. Interviews

1. In an interview on 4/25/16 at 12:30 PM, non-measurable goals were discussed with RN1. She did not dispute the findings.

2. In an interview on 4/26/16 at 11:15 AM, non-measurable goals were discussed with the Director of Nursing. She did not dispute the findings.

3. In an interview on 4/26/16 at 12:10 PM, non-measurable goals were discussed with the Medical Director. He agreed with the findings.

Based on record review and interview, the facility failed to consistently provide physician and Nursing treatment interventions based on individualized needs for five (5) of five (5) sample patients (A1, A2, A3, A4 and A5). Many of the interventions on the treatment plans were listed as generic discipline tasks. These deficiencies result in a failure to provide a basis for purposeful, goal directed treatment and to plan revisions based on individual patient needs and assessments.

A. Record Review

1. Patient A1, Master Treatment Plan dated 4/4/16, had the following nursing and psychiatry interventions for the identified problem "Defensive coping":

Nursing Interventions

a. "Be honest and consistent with patient regarding expectations and enforcing and regarding rules."

b. "Explain to patient what nurses will do before doing it."

c. "Provide general and 15 minute checks for client's safety."

Psychiatry Interventions

a. "Assess mental status daily focusing on depression/med instability."

b. "Monitor meds (medications) daily and adjust as necessary."

c. "Assist nursing staff in teaching and reinforcing [positive] coping skills."

d. "Have client write safety plan."

e. "Make appropriate community referrals."

These interventions were not individualized and were generic discipline functions.

2. Patient A2, Master Treatment Plan dated 4/13/16, had the following nursing and psychiatry interventions for the identified problem "Ineffective individual coping":

Nursing Interventions

a. "Encourage verbalization of feelings, fears, and anxiety."

b. "Explore alternative coping strategies."

c. "Discuss client's plans for living w/o [without] drugs."

d. "Initiate 15 minute precaution checks on client's admission to unit."

Psychiatry Interventions

a. "Evaluate Dx (diagnosis) and recommend psychotropic meds."

b. "Suggest rehab [rehab] possibilities."

These interventions were not individualized and were generic discipline functions.

3. Patient A3, Master Treatment Plan dated 3/1/16, had the following nursing and psychiatry interventions for the identified problem "Potential for violence toward others r/t [related to] delusions of others harming his family":

Nursing Interventions

a. "Monitor general precautions."

b. "Teach new coping skills daily."

c. "Assist clt [client] to complete safety plan."

d. "Medications as ordered and [sic] prn [as needed]."

Psychiatry Interventions

a. "Assess mental status daily focusing on delusions and [sic] and risk to harm others."

b. "Monitor meds [sic] daily and adjust as necessary."

c. "Assist nursing staff in teaching and [sic] reinforcing positive [sic] coping skills."

These interventions were not individualized and were generic discipline functions.

4. Patient A4 (Master Treatment Plan dated 4/12/16) had the following nursing and psychiatry interventions for the identified problem, "Potential for self-harm":

Nursing Interventions

a. "Assist with completing safety plan prn [as needed]."

b. "Help identify triggers for S/I [suicidal ideation]."

c. "Contract for safety q [every] shift and [sic] prn [as needed."

Psychiatry Interventions

a. "Evaluate for change in medication."

b. "Assess the psychiatric Dx [diagnosis]."

These interventions were not individualized and were generic discipline functions.

5. Patient A5, Master Treatment Plan dated 3/17/16, had the following nursing and psychiatry interventions for the identified problem "Alterations in sensorium and [sic] mood r/t [related to] symptom exacerbation of bipolar illness [manic phase]":

Nursing Interventions

a. "Coordinate care with [sic] the psychiatrist assessing clts [client's] clinical sx's [symptom's] q [every] shift and [sic] prn [as needed]."

b. "Assess behavior, and [sic] manic symptoms for signs of clinical improvement."

c. "Provide meds [sic] and address teaching needs daily and [sic] prn [as needed]."

d. "Monitor clt's [client's] sleep pattern each night."

Psychiatric Interventions:

a. "Assess mental status daily focusing on mania and [sic] and thought processes."

b. "Monitor meds daily and adjust as necessary."

c. "Assist nursing staff in teaching and [sic] reinforcing positive [sic] coping skills."

d. "Have client write safety plan."

These interventions were not individualized and were generic discipline functions.

B. Interviews

1. In an interview on 4/25/16 at 12:30 PM, generic, routine, staff interventions were discussed with RN1. She did not dispute the findings.

2. In an interview on 4/25/16 at 12:30 PM, generic, routine, staff interventions were discussed with the Director of Nursing. She did not dispute the findings.

3. In an interview on 4/26/16 at 12:10 PM, generic, routine, staff interventions were discussed with the Medical Director. He agreed with the findings. "We're not capturing all that we are doing."

Based on record review and interview it was determined that the Medical Director failed to monitor the quality of care provided to patients. Specifically, the Medical Director failed to:

1. Ensure that treatment plans delineated short term patient centered goals based on individual needs and/or problem behaviors requiring hospitalization for five (5) of five (5) sample patients (A1, A2, A3, A4 and A5). Many of the short term goals were not consistently described in observable, measurable, and behavioral terms. Others were staff goals (What the staff wanted the patient to accomplish) and not patient goals (What behaviors the patient wanted and/ or needed to accomplish to move toward discharge). These failures hinder the ability of the team to measure change in the patient as a result of treatment interventions and may prolong hospital stays beyond the resolution of the behaviors requiring admission. (Refer to B121)

2. Ensure that Physician and nursing treatment interventions were based on individualized needs for five (5) of five (5) sample patients (A1, A2, A3, A4 and A5). Many of the interventions on the treatment plans were listed as generic discipline tasks. These deficiencies result in a failure to provide a basis for purposeful goal directed treatment and to plan revisions based on individual patient needs and assessments. (Refer to B122)

Based on record review and interview, the Director of Nursing failed to monitor the quality of nursing care provided to patients. Specifically the Director of Nursing failed to:

1. Ensure individualized nursing treatment interventions were included on Master treatment plans for five (5) of five (5) sample patients (A1, A2, A3, A4 and A5). Many nursing interventions were listed as generic nursing tasks. This deficiency resulted in a failure to provide a basis for purposeful, directed treatment and to plan revisions based on individual patient needs and assessments.

A. Record Review

1. Patient A1, Master Treatment Plan dated 4/4/16, had the following generic nursing interventions for the identified problem "Defensive coping":

a. "Be honest and consistent with patient regarding expectations and enforcing and regarding rules."

b. "Explain to patient what nurses will do before doing it."

c. "Provide general and 15 minute checks for client's safety."

2. Patient A2, (Master Treatment Plan dated 4/13/16, had the following nursing interventions for the identified problem, "Ineffective individual coping":

a. "Encourage verbalization of feelings, fears, and anxiety."

b. "Explore alternative coping strategies."

c. "Discuss client's plans for living w/o [without] drugs."

d. "Initiate 15 minute precaution checks on client's admission to unit."

3. Patient A3, (Master Treatment Plan dated 3/1/16, had the following nursing interventions for the identified problem "Potential for violence toward others r/t [related to] delusions of others harming his family":

a. "Monitor general precautions."

b. "Teach new coping skills daily."

c. "Assist clt [client] to complete safety plan."

d. "Medications as ordered and [sic] prn [as needed]."

4. Patient A4, Master Treatment Plan dated 4/12/1,) had the following nursing interventions for the identified problem "Potential for self-harm."

a. "Assist with completing safety plan prn [as needed]."

b. "Help identify triggers for S/I [suicidal ideation]."

c. "Contract for safety q [every] shift and [sic] prn [as needed."

5. Patient A5, Master Treatment Plan dated 3/17/1,) had the following nursing interventions for the identified problem, "Alterations in sensorium and [sic] mood r/t [related to] symptom exacerbation of bipolar illness [manic phase]":

a. "Coordinate care with [sic] the psychiatrist assessing clts [client's] clinical sx's [symptom's] q [every] shift and [sic] prn [as needed]."

b. "Assess behavior, and [sic] manic symptoms for signs of clinical improvement."

c. "Provide meds [sic] and address teaching needs daily and [sic] prn [as needed]."

d. "Monitor clt ' s [client's] sleep pattern each night."

II. Interviews

A. In an interview on 4/25/16 at 12:30 PM, generic, routine, nursing interventions on the treatment plans were discussed with RN1. She did not dispute the findings.

B. In an interview on 4/25/16 at 12:30 PM, generic, routine, nursing interventions were discussed with the Director of Nursing. She did not dispute the findings.