HospitalInspections.org

Based on record review and interview the hospital failed to implement a monitoring process for identified problems related to physical assessments, suicide assessments, updated nursing care plans, psychiatric evaluations which included individualized patient assets, and indicators for all contracted services. Findings:

The hospital could not submit any quality assurance/performance improvement data. Further review revealed no changes had been made until 01/11/11 in the personnel performing QA and none of the described monitors in the plan of correction had been implemented by the Director of Nursing.

In a face to face interview on 01/11/11 at 12:20pm SF28 Contracted RN Director of Performance Improvement indicated she been hired on 01/01/11 and had just begun to revamp the entire quality assurance/performance improvement program. SF28 submitted to the surveyors the revised indicators; however none of which had been implemented. Further she confirmed there was no monitoring of systems/processes at the present time.

In a face to face interview on 01/12/11 at 3:00pm, SF2 Director of Nursing indicated no chart audits were performed to ensure the level of compliance in the use of the newly implemented physical assessment form or if the physicians were individualizing patient assets.

Based on record review, policies and procedures, and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1. Failing to ensure the RN supervised the nursing care of the patients as evidenced by failure to perform an accurate admit assessment and daily assessments according to policies and procedures to identify both medical and psychiatric problems which included risk for suicide, risk for potential alcohol withdrawal, post CVA patients with complaints of tingling sensation around the mouth, identify the presence of a fiberglass cast on admit to include when the fracture occurred and the type of fracture to plan for potential problems including swelling. This was evident in 6 of 6 patients sampled (#F1, #F2, #F3, #F4, #F5, and #F6) (see findings in tag A0395);

2) Failing to ensure the RN implemented a care plan for all identified problems, including following physician's orders for vital signs and lab work for 2 of 6 patients sampled (#F1 and #F4). Patient #F4 was identified with a past history of a CVA and the potential for alcohol withdrawal symptoms for which a nursing care plan was not implemented. #F4 experienced seizure-like symptoms and had to be transferred to an acute care hospital for evaluation. Patient #F1 had a low sodium level lab result on 01/08/11 which required him to be transferred to an acute care hospital for evaluation and for which a nursing care plan was not implemented (see findings in tag 0396); and

3) Failing to ensure the RN assigned the nursing care of each patient in accordance with the specialized competence of the nursing staff as evidenced by failing to perform competency evaluations on RNs, LPNs (licensed practical nurses), and MHTs (mental health techs) prior to assigning patients to their care. This was evident for RN SF11, LPN SF8, LPN SF22, LPN SF23, and MHT SF9, MHT SF12, MHT SF14, MHT SF24, and MHT SF26 out of a sample of 9 personnel files reviewed for competency evaluations (see findings in tag 0397).

Based on record review and interviews the hospital failed to: 1) ensure a patient with a diagnosis of CVA (cerebrovascular accident) was assessed for a CVA when reporting to the RN tingling around the mouth and the patient passing out 20 minutes later requiring transfer to the emergency room for evaluation for 1 of 1 patient reviewed with a diagnosis of CVA from a total sample of 6 patients (#F4); 2) ensure an accurate risk assessment had been performed on 4 of 5 patients with suicidal ideations from a total sample of 6 patients (#F2, #F3, #F4, #F5); 3) ensure a physical assessment was performed on every patient every shift per hospital policy for 5 of 6 sampled patients (#F1, #F2, #F4, #F5, #F6); 4) ensure the RN had performed an assessment for alcohol withdrawal symptoms for 1 of 1 patient treated for alcohol detoxification from a total sample of 6 patients (# F4); 5) ensure the RN assessed a patient's pulse prior to administration of Metoprolol for 1 of 1 patient reviewed with orders for Metoprolol from a total sample of 6 patients (#F4); and 6) ensure the RN performed an accurate admit assessment as evidenced by failure to have documented evidence of the presence of a cast to the right forearm for 1 of 1 patient reviewed with a cast from a total sample of 6 patients (#F4). Findings:

1) Assessment of a patient diagnosed with a CVA:
Review of Patient #F4's medical record revealed she was a 52 year old female admitted on 01/09/11 with a diagnosis of depression.
Review of the history and physical performed on 01/10/11 by Physician SF29 revealed diagnoses of blind left eye, CVA, recent falls, hypertension, coronary artery disease, hypothyroidism, fractured right wrist, bruised hip and forearms, and urine positive for amphetamines.

Review of Patient F4's treatment plan revealed no documented evidence the RN had implemented a plan of care for assessing and monitoring for hypertension, CVA, and alcohol withdrawal.

Review of the "Multi-Disciplinary Progress Note" dated 01/12/11 at 8:25am by RN SF 11 revealed "inform by pt (patient) that there was some tingling around mouth & she has felt this way since this AM (morning) & her vitals were taken earlier & o.k. Informed that staff would watch her closely. Out to OT (occupational therapy) room for group therapy". Review of the "Daily Vital Signs, B.M. (bowel movement), & Wt. (weight) Flow Sheet" revealed Patient # F4's vital signs were taken at 6:00am by a MHT (mental health tech). Further review revealed no documented evidence an assessment had been performed by RN SF 11 after receiving a report from a patient who had a diagnosis of CVA of tingling around the mouth.

Review of the "Multi-Disciplinary Progress Note" dated 01/12/11 at 8:45am by RN SF11 revealed "Informed by OT & staff that pt passed out sitting down in chair @ (at) table & staff reach her before falling to floor. Upon exam in day room pt appears to have had a seizure apt (apparent) etical (ictal) activity noted. Placed in w/c (wheelchair) brought unit with RN & staff placed in bed vital taken ready 172/98 - 97 - 24 - 98.1 - Pt aroused some. Psychiatrist SF 20 present. Pt more alert ... orders receive to transfer to (name of hospital) per ambulance...".

In a face-to-face interview on 01/12/11 at 3:40pm, DON SF2 indicated the RN should have assessed Patient # F4 when she reported tingling around her mouth, since F4 had a prior CVA and a potential for alcohol withdrawal symptoms. When asked by the surveyor what the nurse should assess for alcohol withdrawal symptoms, SF2 indicated a neurological assessment and observation for seizure activity should be performed by the RNs.

In a telephone interview on 01/13/11 at 12:20pm, Physician SF29 confirmed he performed the history and physical for Patient #F4. He further indicated F4 had reported having a prior CVA.

2) Ensure an accurate risk assessment:
Review of the Nursing Mental Status Exam, section titled "Assessment for Potential Risk" revealed the following: Suicidal, Homicidal, Elopement, Seizure, Fall, Aggressive Behavior, Medicine Non-Compliance, Sexual Acting Out (Identified positives addressed in narrative notes).

Patient #F2
Review of the medical record revealed Patient F#2, a 14 year old female, was admitted to the hospital on 01/05/11 with the diagnosis of Depression with Suicidal Ideation. Review of the Nursing Mental Status Exam, section titled " Assessment for Potential Risk: revealed the following: 01/06/11 at 11:30am - Suicidal risk identified. 01/07/11 at 11:00am and 1600 (4:00pm) - no risks identified as evidenced by a 0 with a line through it. 01/08/11 0810 (8:10am) - no documented evidence an assessment had been performed as evidenced by a blank in the section for assessment for potential risk. 01/08/11 at 1830 (6:30pm)- no risks identified as evidenced by a 0 with a line through it. 01/09/11 at 0930 (9:30am) - Suicidal Risk identified. 01/10/11 at 1:25pm - Suicidal Risk identified. 01/11/11 at 1000 (10:00am) no risks identified as evidenced by a 0 with a line through it. 01/12/11 at 0900 (9:00am) - no risks identified as evidenced by a 0 with a line through it. 01/13/11 at 10:30 (am or pm not documented) - no risks identified as evidenced by a 0 with a line through it.
Review of the Nurses' Narrative Notes for Patient #F2 revealed .... "01/09/11 at 10:00am Pt observed on unit in dayroom. She has been very hyper-verbal discussing various topics (news, weather). When asked about her feelings she stated that she doesn't want to go home and would rather stay here. Will continue to monitor patient for safety". Further review revealed no documented evidence of behaviors indicating patient #F2 was a potential risk for suicide. 01/10/11 at 1330 (1:30pm) ..... Patient denies any night terrors continue to monitor for safety".

Patient #F3
Review of the Nursing Initial Assessment revealed Patient #F3, a 15 year old male, was admitted to the hospital on 01/09/11 with the diagnosis of drug overdose with Elavil and Xanax overdose after a two day stay in the Pediatric Intensive Care Unit of the local hospital. Review of the Nursing Mental Status Exam dated 01/11/11 revealed no documented evidence Patient #F3 was assessed for the potential for suicide risk on the 7-3 shift as evidenced by a blank in the section titled " Assessment for Potential Risk " . Review of the Narrative Nursing Notes dated 01/11/11 for the time period of 6:00am through 3:00pm revealed no documented evidence the patient had been assessed for being a possible risk for suicide.

Patient #F4
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with a diagnosis of depression. Review of the Psychiatric Evaluation performed on 01/09/11 by Psychiatrist SF 20 revealed Patient # F4 was a 52 year old female who reported multiple suicide attempts of at least 3 to 4 times. Further review revealed "the patient says she has no recollection of some of her admissions because she has multiple personalities. The patient states this admission was triggered by one of her personalities ... wanting to kill her and causing problems in the past few days...".
Review of the "Nursing Mental Status Exam" dated 01/11/11 at 1735 (5:35pm) by RN SF 27 and the nursing notes revealed no documented evidence of an assessment for potential risk for suicide.

Patient #F5
Review of the History and Physical (H&P) revealed Patient #F5, 38 year old male, was admitted to the hospital on 01/08/11 with the diagnosis of suicidal ideation. Further review of the section titled "Risk Assessment" revealed the patient was being admitted because of current suicidal ideation and with a history of impulsive behavior and multiple suicidal behaviors, the patient was considered to be a high risk for self-harm.

Review of the Nursing Mental Status Exam, section titled "Assessment for Potential Risk" for Patient #F5 revealed the following: 01/08/11 at 0930 (9:00am) day of admit - no risks identified as evidenced by a 0 with a line through it. 01/10/11 no documented evidence submitted by the hospital that a mental status exam had been performed. 01/11/11 at 0815 (8:15am) - no risks identified as evidenced by a 0 with a line through it. 01/11/11 at 1550 (3:50pm) - no risks identified as evidenced by a 0 with a line through it. 01/12/11 at 0830 (8:30am) - no risks identified as evidenced by a 0 with a line through it. 01/13/11 at 0825 (8:25am) - no documented evidence the potential for risk had been assessed as evidenced by a blank in this section.

Review of the Nurses' Narrative Notes for Patient #F5 revealed ... .... 01/08/11 at 1830 (6:30pm) "Remains quiet and withdrawn from peers. Only speaks when spoken to. Complains of being tired and wanting to lie down. 01/08/11 at 1930 (7:30pm) Observed on unit, withdrawn from others. Responds when to questions asked. Reports feeling suicidal at times and expresses this is why he is here. 01/09/11 at 1450 (2:50pm) ..... Continues to speak of suicidal ideations frequently. 01/09/11 at 1830 (6:30pm) Patient observed on unit, very little interaction with peers. Report continues to feel depressed and suicidal".

In a face to face interview on 01/12/11 at 3:00pm S2, Director of Nursing, indicated the nursing staff was inserviced on the new physical assessment forms. Further she indicated the RN was responsible for assessing his/her patient each shift which included both a physical and mental assessment. S2 indicated that on the mental status form all sections should be addressed including the one for risk assessment for potential for suicide. The DON indicated no chart audits were being performed at the present time so she was not aware of non-compliance.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 06/03/10 and submitted by Consultant SF 7 as the hospital's current policy for assessment and reassessment, revealed, in part, "...The following information will be included on the Admission Screening/Assessment form: a. Notation of high risk areas (suicidal or homicidal ideation, acute psychosis, acute medical problems, potential risk for falls, sexual acting out behaviors)... Nursing Admission Assessment ...The patient's mental status and any present evidence of risk for harm to self or others, falls, seizure, aggressive behavior... will be assessed by the RN and documented in the admission nursing progress note. ... Nursing Reassessment Post admission re-assessment of a patient's physical status will be accomplished by the RN charge nurse in the event of an injury, return form therapeutic assignment (pass), at the time of discharge or any other time physical impairments may be identified by staff...". Further review of the entire policy revealed no documented evidence the policy addressed re-assessment by the RN of the patient's potential for suicide risk.

3) Ensure a physical assessment was performed on every patient every shift per hospital policy:
Patient # F1
Review of Patient # F1's medical record revealed he was a 10 year old male admitted on 01/06/11 with a diagnosis of intermittent explosive disorder. Review of the Psychiatric Evaluation performed by Psychiatrist SF 20 on 01/07/11 revealed diagnoses of psychotic disorder, intermittent explosive disorder, history of conduct disorder, history of ADHD (attention deficit hyperactive disorder). Further review revealed his justification for inpatient hospitalization was a potential danger to self as evidenced by his report of hearing voices that tell him to kill himself and the potential danger to others as evidenced by his thoughts to kill others.
Review of the "Multi-Disciplinary Physical Assessment Tool" for F1 revealed the following:
01/07/11 - 11-7 shift - no documented evidence of a neurologic, skin, HEENT (head, eyes, nose, throat), genitourinary, musculoskeletal, pain, and psychosocial assessment had been performed;
01/08/11 - 11-7 shift - no documented evidence of a neurologic, skin, HEENT, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed;
01/09/11 - 11-7 shift - no documented evidence a neurologic, skin, HEENT, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed; no documented evidence of the signature of the RN completing the respiratory assessment and sleep evaluation;
01/10/11 - 11-7 shift - no documented evidence of a neurologic, skin, HEENT, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed; no documented evidence of the signature of the RN completing the respiratory assessment and sleep evaluation; and
01/11/11 - 11-7 shift - no documented evidence of a neurologic, skin, HEENT, gastrointestinal, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed.

Patient # F2
Review of the medical record for Patient #F2, a 14 year old female, revealed she was admitted to the hospital on 01/05/11 with the diagnosis of depression with suicidal ideation. Review of the Nursing Mental Status Exam for F3 revealed no documented evidence the patient was assessed for the potential risk of suicide on 01/08/11.
Review of the Multidisciplinary Physical Assessment Tool for F5 revealed the following:
01/09/11 3-11 shift: No documented evidence a psychosocial assessment was performed.
01/09/11 11-7 shift: No documented evidence an assessment was performed.

Patient # F4
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with a diagnosis of depression. Review of the "Multi-Disciplinary Physical Assessment Tool" for F4 revealed the following:
01/08/11 - 11-7 shift - no documented evidence a neurologic, skin, HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed;
01/09/11 - 7-3 shift - no documented evidence a gastrointestinal, genitourinary, and psychosocial assessment had been performed;
01/09/11 - 3-11 shift - no documented evidence a genitourinary assessment had been performed;
01/09/11 - 11-7 shift - no documented evidence a neurologic, skin, HEENT, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed;
01/10/11 - 7-3 shift - no documented a gastrointestinal, genitourinary, and psychosocial assessment had been performed;
01/10/11 - 3-11 shift - no documented evidence a genitourinary assessment had been performed;
01/10/11 - 11-7 shift - no documented evidence a neurologic, skin, HEENT, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed;
01/11/11 - 7-3 shift - no documented a gastrointestinal, genitourinary, and psychosocial assessment had been performed;
01/11/11 - 3-11 shift - no documented evidence a psychosocial and nutrition assessment had been performed; and
01/11/11 - 11-7 shift - no documented evidence a neurologic, skin, HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, pain, psychosocial, and nutrition assessment had been performed.

Patient # F5
Review of the medical record for Patient #F5, a 38 year old male, revealed he was admitted to the hospital on 01/08/11 with the diagnosis of suicidal ideations. Review of the Multidisciplinary Physical Assessment Tool for F5 revealed the following:
01/08/11 7-3 shift: No documented evidence a gastrointestinal, genitourinary or psychosocial assessment was performed as required by the multidisciplinary tool.
01/09/11 7-3 shift: No documented evidence a gastrointestinal, genitourinary, musculoskeletal or psychosocial assessment had been performed.
01/09/11 11-7 shift: No documented evidence an assessment was performed.
01/10/11 7-3 shift: No documented evidence a gastrointestinal, genitourinary, or psychosocial assessment had been performed.
01/10/11 11-7 shift: No documented evidence an assessment was performed.
01/11/11 7-3 shift: No documented evidence a gastrointestinal, genitourinary, or psychosocial assessment had been performed.
01/11/10 3-11 shift: No documented evidence a psychosocial or nutritional assessment was performed.
01/12/11 7-3 shift: No documented evidence a gastrointestinal, genitourinary, or psychosocial assessment had been performed.
01/12/11 11-7 shift: No documented evidence an assessment was performed.
01/13/11 7-3 shift: No documented evidence an assessment on food consumption had been assessed.

Patient # F6
Review of Patient # F6's medical record revealed he was a 20 year old male admitted on 01/10/11 with a diagnosis of depression. Review of the "Multi-Disciplinary Physical Assessment Tool" for F4 revealed the following:
01/11/11 - 7-3 shift - no documented evidence a gastrointestinal, genitourinary, and psychosocial assessment had been performed;
01/11/11 - 3-11 shift - no documented evidence a psychosocial and nutrition assessment had been performed;
01/11/11 - 11-7 shift - no documented evidence a neurologic, skin, HEENT, cardiovascular, gastrointestinal, genitourinary, pain, and psychosocial assessment had been performed;
01/12/11 - 7-3 shift - no documented evidence a gastrointestinal, genitourinary, musculoskeletal, and psychosocial assessment had been performed;
01/12/11 - 3-11 shift - no documented evidence a respiratory and cardiovascular assessment had been performed;
01/12/11 - 11-7 shift - no documented evidence a neurologic, skin, HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, pain, psychosocial, and nutrition assessment had been performed; and
01/13/11 - 7-3 shift - no documented evidence a psychosocial and nutrition assessment had been performed.

In a face to face interview on 01/12/11 at 3:00pm S2, Director of Nursing, indicated the nursing staff was inserviced on the new physical assessment forms. Further she indicated the RN was responsible for assessing his/her patient each shift which included both a physical and mental assessment. S2 indicated that on the mental status form all sections should be addressed including the one for risk assessment for potential for suicide. The DON indicated no chart audits were being performed at the present time so she was not aware of non-compliance.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 12/29/10 and submitted by Director of Nursing SF2 as their current policy for assessment and re-assessment which had not been approved by the governing body as of the time of this survey, revealed, in part, "...All other required assessments will be completed within the time frames specified for each discipline. ... Physical Assessments/Reassessments using the Multi-disciplinary Physical Assessment Tool will be done on the 7-3 shift, and 3-11 shift by the RN Charge Nurse beginning the following shift after admission within 3 - hours from the beginning of the shift. Sleep evaluations will be done by the Charge RN on the 11-7 shift within 3 - hours, and additional physical assessments will be done on the 11-7 shift when applicable. Additional assessments are ordered by the physician when further diagnostic clarification or treatment recommendations are needed...".

4) Assessment for alcohol withdrawal symptoms:
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with a diagnosis of depression. Review of the physician's orders revealed an order for librium detoxification protocol from alcohol.

Review of the entire medical record revealed no documented evidence Patient # F4 was assessed by the RN for signs and symptoms of alcohol withdrawal. Further review revealed no documented evidence a care plan was developed and implemented for the potential for alcohol withdrawal.

Review of the "Multi-Disciplinary Progress Note" dated 01/12/11 at 8:25am by RN SF 11 revealed "inform by pt (patient) that there was some tingling around mouth & she has felt this way since this AM (morning) & her vitals were taken earlier & o.k. Informed that staff would watch her closely. Out to OT (occupational therapy) room for group therapy". Review of the "Daily Vital Signs, B.M. (bowel movement), & Wt. (weight) Flow Sheet" revealed Patient # F4's vital signs were taken at 6:00am by a MHT (mental health tech). Further review revealed no documented evidence an assessment had been performed by RN SF 11 after receiving a patient's report of tingling around the mouth.

Review of the "Multi-Disciplinary Progress Note" dated 01/12/11 at 8:45am by RN SF11 revealed "Informed by OT & staff that pt passed out sitting down in chair @ (at) table & staff reach her before falling to floor. Upon exam in day room pt appears to have had a seizure apt (apparent) etical (ictal) activity noted. Placed in w/c (wheelchair) brought unit with RN & staff placed in bed vital taken ready 172/98 - 97 - 24 - 98.1 - Pt aroused some. Psychiatrist SF 20 present. Pt more alert ... orders receive to transfer to (name of hospital) per ambulance...".

In a face-to-face interview on 01/12/11 at 3:40pm, DON SF2 indicated the RN should have assessed Patient # F4 when she reported tingling around her mouth, since F4 was had the potential for alcohol withdrawal symptoms and had a diagnosis of CVA. When asked by the surveyor what the nurse should assess for alcohol withdrawal symptoms, SF2 indicated a neurological assessment and observation for seizure activity should be performed by the RNs.

In a face-to-face interview on 01/13/11 at 8:35am, Psychiatrist SF 20 indicated he would expect the RN assessment of a patient with the potential for alcohol withdrawal to include vital signs, listening to reports by the patient of feeling funny, an unsteady gait, confusion, sweaty palms, but especially monitoring vital signs. SF 20 indicated he was not aware the nurses were not monitoring vital signs every 4 hours as ordered. He further indicated he expected Patient # F4's seizure was related to alcohol withdrawal.

In a face-to-face interview on 01/13/11 at 9:00am, RN SF 27 indicated an assessment for alcohol withdrawal should include observation for sweating, shaking, seizures, and hallucinations. When asked by the surveyor if monitoring vital signs should be done, SF 27 answered yes, and she indicated the pulse may be elevated and the blood pressure either elevated or low. She confirmed that vital signs were monitored every 4 hours as ordered, and it would be reasonable to expect that monitoring the blood pressure would be an important assessment for for alcohol withdrawal.

In a telephone interview on 01/13/11 at 12:50pm, RN SF 11 indicated symptoms for which she would observe for alcohol withdrawal would be trembling, shaking, loss of balance, change in neurological status, and vital sign changes. She confirmed she did not document any assessment for alcohol withdrawal, and if vital signs were not performed as ordered, Patient # F4's vital signs could not be used to monitor for alcohol withdrawal.

In a second telephone interview with RN SF 11 on 01/13/11 at 1:45pm, SF 11 indicated she looked at the vital signs taken at 6:00am on 01/12/11, and she didn't "think she needed to re-check the vital signs" when #F4 reported tingling around the mouth.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 06/03/10 and submitted by Consultant SF 7 as the hospital's current policy for assessment and reassessment, revealed, in part, "...Nursing Reassessment Post admission re-assessment of a patient's physical status will be accomplished by the RN charge nurse in the event of an injury, return form therapeutic assignment (pass), at the time of discharge or any other time physical impairments may be identified by staff...".

5) Assessment of a patient's pulse prior to administration of Metoprolol:
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with a diagnosis of depression.
Review of the "Physician's Orders" dated 01/09/11 at 1:30am revealed an order for Metoprolol XL 50 mg (milligrams) by mouth every day.

Review of the "Drug Information Handbook for Nursing", 8th edition, revealed, in part, "...Metoprolol ...Patient Education: ... Oral: ... Take pulse daily, prior to medication and follow prescriber's instruction about holding medication...".

Review of the Medication Administration Record for Patient #F4 revealed no documented evidence F4's pulse had been assessed prior to administration of Metoprolol on 01/09/11, 01/10/11, 01/11/11, and 01/12/11.

In a face-to-face interview on 01/13/11 at 10:30am, DON SF 2 confirmed there was no documented evidence that Patient #F4's blood pressure or pulse had been assessed prior to the administration of Metoprolol from 01/09/11 through 01/12/11.

6) Accurate admit assessment:
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with a diagnosis of depression.

Review of the "Initial Screening/Nursing Assessment" performed by RN SF 27 on 01/09/11 at 3:40am revealed no documented evidence of a cast to the right forearm.

Review of the Psychiatric Evaluation performed by Psychiatrist SF 20 on 01/09/11 revealed "fracture of right forearm (in a cast)".

In a face-to-face interview on 01/13/11 at 9:00am, RN SF 27 confirmed her admission assessment of Patient #F4 did not include the presence of a cast to her right forearm. She indicated she should have documented it on page 10 with a review of physical findings.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 06/03/10 and submitted by Consultant SF 7 as the hospital's current policy for assessment and reassessment, revealed, in part, "...A review of systems will be completed by the RN with documentation of any identified medical problems. The patient's body will be examined for any marks, ie. (that is) bruises, swelling, scratches, and appropriate documentation noted...".


25065

Based on record and interview, the hospital failed to ensure: 1) the nursing staff developed and kept current a nursing care for each patient as evidenced by failure to have patients' medical problems addressed in the care plan and have the care plan updated with changes in the patients' condition for 2 of 2 patients reviewed with medical diagnoses from a total sample of 6 patients (#F1, #F4) and 2) the nursing staff implemented the physician's orders for 2 of 6 sampled patients for vital signs (#F4) and labs (#F1). Findings:

1) Medical diagnoses addressed in the care plan:
Patient #F1
Review of Patient #F1's medical record revealed he was a 10 year old male admitted on 01/06/11 with a diagnosis of Intermittent Explosive Disorder.

Review of Patient #F1's lab results revealed the sodium level drawn on 01/08/11 was 111, a critical value. Further review revealed once the result was called to the hospital, an order was given by Psychiatrist SF 20 to transfer Patient #F1 to the emergency room for evaluation of the low sodium level.

Review of Patient #F1's treatment plan revealed no documented evidence it was updated upon F1's return from the hospital to reflect assessment and monitoring for complications related to the low sodium level.

In a face-to-face interview on 01/12/11 at 10:55am, Director of Nursing (DON) SF2 confirmed Patient #F1's care plan should have been updated to include the monitoring for complications from the low sodium level. She further indicated no chart audits were being performed at the present time, so she was not aware of non-compliance.

Patient #F4
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with a diagnosis of depression.

Review of the history and physical performed on 01/10/11 by Physician SF29 revealed diagnoses of blind left eye, CVA, recent falls, hypertension, coronary artery disease, hypothyroidism, fractured right wrist, bruised hip and forearms, and urine positive for amphetamines.

Review of Patient F4's treatment plan revealed no documented evidence the RN had implemented a plan of care for assessing and monitoring for hypertension, CVA, and alcohol withdrawal.

Review of the "Multi-Disciplinary Progress Note" for 01/12/11 at 8:25am by RN SF 11 revealed Patient #F4 reported tingling around the mouth. Further review revealed SF11 reviewed the vital signs taken at 6:00am that morning. There was no documented evidence of an assessment by SF11 of Patient #F4, who had a diagnosis of a prior CVA, for signs and symptoms of a CVA. Further review revealed 20 minutes after the patient's complaint, F4 passed out and had to be transferred to the emergency room for evaluation.

In a face-to-face interview on 01/12/11 at 3:40pm, DON SF2 indicated Patient #F4's care plan should have included the medical treatment for CVA, hyprtension, and alcohol withdrawal.

2) Implementing physician's orders:
Patient #F4
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with a diagnosis of depression.

Review of the physician's orders revealed an order to take vital signs every four hours.

Review of the entire medical record revealed vital signs were taken as follows:
01/09/11 at 2:47am, 6:00am, and 9:00pm;
01/10/11 at 6:00am and 11:00am;
01/11/11 at 3:00am, 6:00am, 12:00pm, and 5:35pm; and
01/12/11 at 6:00am.
There was no documented evidence vital signs were taken every 4 hours as ordered by the physician.

In a face-to-face interview on 01/13/11 at 9:00am, RN SF 27 confirmed the vital signs were not taken every 4 hours as ordered.

In a telephone interview on 01/13/11 at 12:50pm, RN SF 11 indicated she usually asked the MHTs (mental health techs) to notify her if vital signs were abnormal. She further indicated she did not routinely check the graphic sheet to check if vital signs were taken as ordered.

Patient #F1
Review of Patient #F1's medical record revealed he was a 10 year old male admitted on 01/06/11 with a diagnosis of Intermittent Explosive Disorder.

Review of Patient #F1's physician's admit orders of 01/06/11 at 5:45pm revealed an order to obtain a comprehensive metabolic panel, complete blood count, Free T4 (thyroid), TSH (thyroid stimulating hormone), RPR (rapid plasma reagin), urine drug screen, and fasting lipids.

Review of the lab results revealed the lab was drawn on 01/08/11 at 6:33am, more than 24 hours after the order was given.

In a face-to-face interview on 01/12/11 at 10:55am, DON SF 2 confirmed the blood was drawn more than 24 hours after the order was given for Patient # F1.





25065

Based on record review and interview, the hospital failed to ensure the RN (registered nurse) assigned the nursing care of each patient according to the needs of the patient and the specialized qualifications, experience, and/or competence of the nursing staff by having: 1) no documented evidence of an assessment of competency for 1 of 1 RN personnel file reviewed for assessment of competency from a total of 7 full-time RNs and 12 PRN (as needed) RNs (SF 11); 2) no documented evidence of an assessment of competency for 3 of 5 LPN (licensed practical nurse) personnel files reviewed for assessment of competency from a total of 8 full-time LPNs and 5 PRN LPNs (SF 8, SF 22, SF 23); and 3) no documented evidence of an assessment of competency for 5 of 5 MHT (mental health tech) personnel files reviewed for assessment of competency from a total of 51 full-time MHTs and 16 PRN MHTs (SF 9, SF 12, SF 14, SF 24, SF 26). Findings:

1) RN
Review of SF 11 RN's personnel file revealed a post test for "Review of Adverse Drug Reactions, Medication Errors, SALAD Drugs and Maximum Allowable Dosages" dated 01/06/11 with no documented evidence of review and scoring of the test by the presenter of the in-service R Ph (registered pharmacist) SF 25. Further review revealed the post test for the "Handle With Care" course (non-violent crisis intervention) dated 12/16/10 had a score of 90% (per cent). Further review revealed no documented evidence of the review of the test by the presenter of the course, and there was no documented evidence of an observed assessment of RN SF 11's competency to perform the interventions taught in the course.

2) LPNs
SF 8
Review of LPN SF 8's personnel file revealed a pretest and post test for "Review of Adverse Drug Reactions, Medication Errors, SALAD Drugs and Maximum Allowable Dosages" dated 01/06/11 with no documented evidence of review and scoring of the test by the presenter of the in-service R Ph SF 25. Further review revealed the post test for the "Handle With Care" course dated 12/17/10 had a score of 90%. Further review revealed no documented evidence of the review of the test by the presenter of the course, and there was no documented evidence of an observed assessment of LPN SF 8's competency to perform the interventions taught in the course.

SF 22
Review of LPN SF 22's personnel file revealed the "Handle With Care" pretest was completed on 12/30, with no documented evidence of the year, with a score of 90%. Further review revealed the "Handle With Care" post test was completed on 12/30, with no documented evidence of the year, with a score of 85%. Further review revealed no documented evidence that the course presenter had reviewed the tests and provided remediation for the questions answered incorrectly. There was no documented evidence of an observed assessment of LPN SF 22's competency to perform the interventions taught in the course.

SF 23
Review of LPN SF 23's personnel file revealed she was hired on 11/15/10. Review of the pretest and post test for "Review of Adverse Drug Reactions, Medication Errors, SALAD Drugs and Maximum Allowable Dosages" dated 01/06/11 had no documented evidence that it was reviewed and scored by the presenter of the in-service R Ph SF 25. Review of LPN SF 23's "General Orientation Skills Checklist" revealed the column titled "met criteria" had a check mark in all areas with no documented evidence of signature by the preceptor and the date of assessment of competency. Further review revealed the "Handle With Care" post test completed on 12/30/10 was scored 95%. There was no documented evidence of an observed assessment of LPN SF 22's competency to perform the interventions taught in the course. Review of the hand hygiene and infection control post tests completed on 11/15/10 revealed no documented evidence the tests had been reviewed to determine competency or if there was need for remediation. Review of the post tests for developmental disorders competency, anxiety competency, age-specific competencies, and MHT age-specific competency dated 11/16/10 revealed no documented evidence the tests had been reviewed to determine competency or if there was need for remediation.

3) MHTs
MHT SF 9
Review of MHT SF 9's personnel file revealed the "Handle With Care" post test completed 11/30/10 as part of her instructor certification had a score of 80%. Further review revealed no documented evidence of an observed assessment of MHT SF 9's competency to perform the interventions taught in the course, and there was no documented evidence of re-education to address the questions answered incorrectly on the post test.

MHT SF 12
Review of MHT SF 12's personnel file revealed she was hired 12/13/10. Further review revealed no documented evidence of prior psychiatric work experience. Review of the "General Orientation Skills Checklist" revealed no documented evidence of an assessment of MHT SF 12's competency with medical records department responsibilities to include documentation, confidentiality, charting in the medical record, and maintenance of patient's charts. Further review revealed "Handle With Care" competency of verbal and physical interventions was assessed by Staff Development Coordinator RN SF 3 who had not been certified as an instructor. Review of the "Vital Signs" post test dated 12/17/10 revealed a score of 100%, while question 5 and 6 (true/false) were marked in a manner that one could not determine if the answer was T or F, and there was no documented evidence of the signature of the person who reviewed the test answers to determine competency.
Review of MHT SF 12's post tests revealed the following tests with dates and scores:
12/14/10 - "Employee Orientation Post Test Performance Improvement, Patient Rights, Incident Reporting, Seclusion/Restraint, Documentation, Identifying & (and) Reporting Abuse & Neglect" - 88%;
12/14/10 - "Orientation In-service Post Quiz" - 85%;
12/16/10 - "Anxiety Competency Exam" - 80%;
12/16/10 - "Age-Specific Competency Post Test" - 80%;
12/17/10 - "Normal Growth and Development Competency Exam" - 85%;
12/17/10 - "Cultural Diversity Competency Exam" - 75%;
12/17/10 - "Developmental Disorders Competency Exam" - 88%;
No documented evidence of the name of the staff member or the date the post test was completed - "The Hand Hygiene Guideline Post Test" - 80%;
No documented evidence of the name of the staff member or the date the post test was completed (two separate tests in file) - "Infection Control: What You Need To Know Post Test" - 50% and 80%;
No documented evidence of the name of the staff member or the date the post test was completed - "MRSA (methicillin resistant staph aureus) Post Presentation" - no documented evidence of the reviewer of the post test and a score; no documented evidence of answers to three of six questions.
Further review of the entire personnel file revealed no documented evidence MHT SF 12 had received re-education to address the questions that had been answered incorrectly.

MHT SF 14
Review of the personnel record for SF14, Mental Health Technician revealed she was hired on 12/13/10 and completed general orientation on 12/17/10. Review of her application revealed no documented evidence of experience working with psychiatric patients. Review of written post-test scoring for SF14 revealed the following: Infection Control: 70%; Cultural Diversity: 75%; Developmental Disorders: 78%; and Hand Hygiene: 60%. Further review of the file for SF24 revealed no documented evidence the employee had been remediated in the deficient areas.

MHT SF 24
Review of the personnel record for SF24, Mental Health Technician revealed she was hired on 12/13/10 and completed general orientation on 12/17/10. Further review revealed the following scores for written testing: Infection Control: 80%; Developmental Disorders: 72%; General Orientation Post Quiz: 75%; and Vital Signs Post Test: 62%. Further review of the file for SF24 revealed no documented evidence the employee had been remediated in the deficient areas.

MHT SF26
Review of the personnel record for SF26, Mental Health Technician revealed she was hired on 12/13/10 and completed general orientation on 12/17/10. Further review revealed the following scores for written testing: General Orientation Post Quiz: 75%; and Vital Signs Post Test: indicated SF16 received a score of 100%. However 3 of the 8 true/false questions were answered with both a T and F which would have made the corrected score 62%. Further review of the file for SF24 revealed no documented evidence the employee had been remediated in the deficient areas.

In a face-to-face interview on 01/11/11 at 3:35pm, DON SF 2 confirmed there was no documented evidence that an observation of the demonstration of interventions taught at the "Handle With Care" course had been conducted to determine the competency of the nursing staff to perform such techniques. She offered no explanation for the lack of re-education of nursing staff when competency testing scores were low.

Review of the hospital's policy titled "Plan for the Provision of Patient Care - 2008", revised 02/26/08, revealed, in part, "...Staff Development (education) Department ... Objectives: 1. Provide information and certification to Crossroads employees and its associates involving the mandatory education areas, which are: ... g. STEPS ...".

Review of the hospital policy titled "Staff Development - Inservice", revised 07/03/00, revealed, in part, "...All hospital employees will receive mandatory orientation at the beginning of their employment. Mandatory orientation includes education on the following CRH (Crossroads Regional Hospital) policy and procedures: ...5. Non-Violent Crisis Intervention Techniques (Clinical Staff) ... All clinical staff members will be re-certified annually in non-violent crisis intervention techniques (S.T.E.P.S., CPI [crisis prevention intervention], PMAB [Prevention and Management of Aggressive Behavior] and CPR. The re-certification process will consist of cognitive and behavioral education and will include written tests as well as skills checklists ...".

Review of the hospital policy titled "Initial Employment Period", revised 05/01/02, revealed, in part, "...The initial employment period, which is generally the first ninety (90) days of employment will be heavily concentrated on training in the new role. During this period of time, the supervisor will observe and determine the employee's ability to do the work which is assigned, as well as suitability for the position with regard to facility standards of attitude, punctuality and attendance. ...".





25065

Based on record review and interview, the hospital failed to ensure the psychiatric evaluation included an inventory of the patient's assets in descriptive terms as evidenced by failure to have patient-specific personal attributes documented that could be used to develop a meaningful treatment plan and therapeutic groups for 5 of 6 sampled medical records reviewed for psychiatric evaluations from a total sample of 6 medical records (F1, F2, F4, F5, F6). Findings:

Review of Patient # F1's psychiatric evaluation performed by Psychiatrist SF20 revealed the assets were adequate housing, good health, and patient lives at home with both parents and younger brother. There was no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Review of Patient #F2's psychiatric evaluation performed by Psychiatrist SF20 revealed her assets were "average intelligence, adequate housing and good health". There was no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Review of Patient # F4's psychiatric evaluation performed by Psychiatrist SF 20 revealed her assets were hobbies, accepts need for treatment, average IQ (intelligence quotient), capable of insight, and supportive family. There was no documented evidence of specific hobbies enjoyed by Patient # F4 and patient- specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Review of Patient #F5's psychiatric evaluation performed by Psychiatrist SF20 revealed his assets were " accepts needs for treatment, average IQ and capable of insight". There was no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

Review of Patient # F6's psychiatric evaluation performed by Psychiatrist SF20 revealed her assets were "hobbies, physically intact, average IQ, ambition, and supportive family". There was no documented evidence of patient-specific personal attributes that could be used to develop a meaningful treatment plan and therapeutic groups.

In a face to face interview on 01/11/11 at 3:10pm SF2 Director of Nursing indicated the physicians were inserviced on the need to perform an inventory of the patient's assets using descriptive terms and patient specific. Further SF2 indicated no chart audits had been performed to determine if the inservice was effective.

Review of the hospital policy titled "Assessments, Initial Screening and Other", revised 06/03/10 and submitted by Consultant SF 7 as the hospital's current policy for assessments and psychiatric evaluations, revealed, in part, "...The admitting/attending psychiatrist or designated clinician ... will interview patient and complete the hand-written psychiatric evaluation form so that it is on the chart within 24 hours including the following information: ... Inventory of patient assets (in descriptive, not interpretive, terms) ...".






25065

Based on record review and interview, the hospital failed to ensure the patients' treatment plans included short-term and long-term goals that were patient-specific, written as observable, measurable patient behaviors, and had an expected achievement date as evidenced by failure to document goals in a manner to allow them to be measured by observation of patient behaviors and to include an expected achievement date for 3 of 6 patients' treatment plans reviewed from a total sample of 6 patients (# F1, # F4, # F6). Findings:

Patient # F1
Review of Patient # F1's medical record revealed he was admitted on 01/06/11 with the diagnosis of Intermittent Explosive Disorder. Review of Patient # F1's Psychiatric Evaluation performed by Psychiatrist SF 20 on 01/07/11 revealed his initial treatment goals were to control and sustain absence of suicidal ideations, control and sustain absence of homicidal ideations, control or decrease of aggressive behavior, and improvement and stability of thought content.
Review of Patient # F1's "Initial Treatment Plan" revealed nursing's identified problem was aggressive behavior. Further review revealed the short-term goal was "no harm to others while at CRH (Crossroads Regional Hospital). The long-term goal was that the patient would develop positive skills to deal with anger. There was no documented evidence of an expected achievement date for the long-term goal, and there was no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors.
Review of the recreational therapist's treatment plan revealed the identified problem for Patient # F1 was aggression. The short-term goal was to develop methods of expressing angry feelings with no documented evidence of an expected achievement date. The long-term goal was that the patient would be able to make a list of leisure skills and set realistic goals by discharge. Further review revealed no documented evidence the short-term and long-term goals were written in a manner to allow them to be measured by observation of patient behaviors.
Review of the educational treatment plan revealed the short-term goal was to maintain the present level of attainment at grade levels, and the long-term goal was to be able to return to school and function with no interference. Further review revealed no documented evidence of an expected date of achievement of either goal, and there was no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors.

Patient # F4
Review of Patient # F4's medical record revealed she was admitted on 01/09/11 with the diagnosis of depression. Review of the Psychiatric Evaluation performed by Psychiatrist SF 20 on 01/09/11 revealed her initial treatment goals were control or decrease any aggressive behavior, improve mood, improve and stabilize thought processes/content, and detoxification from alcohol.
Review of the "Initial Treatment Plan" revealed social services' identified problem for Patient # F4 was altered state of mind. Nursing's identified problem was depression. Further review revealed nursing's short-term goal for Patient # F4 was for F4 to remain safe while at the hospital, and the long-term goal was that F4 would utilize positive coping skills to deal with life stressors. There was no documented evidence of an expected date of achievement of either goal, and there was no documented evidence the goals were written in a manner to allow them to be measured by observation of patient behaviors.

Patient # F6
Review of Patient # F6's medical record revealed he was admitted on 01/10/11 with a diagnosis of depression. Review of the Psychiatric Evaluation performed by Psychiatrist SF 20 on 01/11/11 revealed his initial treatment goals were control and sustain absence of suicidal ideations, improved mood, and improvement and stability of thought processes/content.
Review of Patient # F6's "Initial Treatment Plan" revealed nursing identified the problem of depression/psychosis. Further review revealed the short-term goal was "Pt's (patient's) mood will improve, psychosis will decrease or resolve and suicidal risk will resolve within one week", and the long-term goal was "pt safety will be maintained while hospitalized". Further review revealed no documented evidence the short-term and long-term goals were patient-specific, written as observable, measurable patient behaviors, and had an expected achievement date.

In a face-to-face interview on 01/12/11 at 10:55am, Director of Nursing (DON) SF 2 indicated the staff nurses reported patient problems and status of the patient to Treatment Team RN (registered nurse) SF 6 who attended the treatment team meetings. DON SF 2 further indicated the short-term and long-term goals established by the nursing staff were not patient-specific and written in a manner to allow them to be measured related to patient behaviors. SF 2 further indicated she had not presented in-services to the clinical staff on updating care plans.

Review of Policy No. AS-00-011 titled "Assessment and Treatment of Patients", last revised 01/09/08 and submitted as the one currently in use, revealed no documented evidence the goals (short or long term) were to be written in a manner that allowed them to be measured.





25065

Based on record review and interview the hospital failed to employ adequate numbers of certified Activity Therapists resulting in recreational therapy services provided 5 days a week throughout the hospital to meet the needs of the hospital population. Findings:

Review of Policy No. LD-00-003 titled "Plan for the Provision of Patient Care", last revised 02/26/08 and submitted as the one currently in use revealed Recreational Therapy Services are provided seven (7) days a week throughout the hospital. The services provided are 1. Evaluation of each service. 2. Scheduled therapy for selected services. 3. Group sessions".

In a face to face interview on 01/12/11 at 11:00am SF1 Administrator indicated the hospital is in the process of getting SF21 Activity Therapist certified. Further SF1 indicated he has been advertising in the newspaper for an additional therapist, but has no applicants at the present time.