HospitalInspections.org

Based on observation, record review and interview, the facility failed to develop a comprehensive care plan for each patient that included measurable objectives and timetables to meet patient's medical, nursing, and mental needs that were identified in the multidisciplinary assessments. The facility failed to develop care plan problems, goals and interventions for 1 of 5 closed record sampled patients who attempted suicide immediately prior to being admitted to the hospital (#1), 1 of 3 active sampled patients who exhibited suicidal ideations (#7), 1 of 5 closed record sampled patients who eloped from another facility prior to being admitted (#2), and 1 of 3 active sampled patients from a total of 5 currently on the BMU with fall risks (#8) from a total sample of 8 and total census of 10 patients on the BMU. Findings:

1. Review of the closed chart for patient #1 revealed she was admitted to the BMU on 1/13/11 and discharged on 2/2/11 with diagnoses including schizoaffective disorder and a history of polysubstance abuse.

Review of the PEC dated 1/13/11 at 11:29 a.m. and the CEC dated 1/14/11 at 5:05 p.m. reflected they were initiated because she had attempted to commit suicide by OD.

Review of the Physician's Admit Orders dated 1/13/11 at 8:15 p.m. revealed an order for every 15 minute checks RT suicide.

Review of the BMU Psychiatric Evaluation dated 1/14/11 at 6:00 p.m. indicated the patient's chief complaint was "I tried to commit suicide?" Further review reflected she had overdosed on 40 Nyquil and 40 Excedrin PM.

Review of the Multidisciplinary Treatment Plan dated 1/13/11 (no time), the Treatment Problem List (no date/no time) and care plan problems, goals and intervention revealed problem areas were initiated for depressed mood and altered thoughts.

There was no documentation to reflect care plan problems, goals or interventions were initiated to meet the patient's suicidal needs and previous attempt.

Interview with S1 RN on 2/16/11 at 9:55 a.m. revealed the facility did have a specific care plan with problems, goals and interventions RT suicidal ideations/suicide attempts.

Review of a blank care plan sheet provided by S1 RN at the above time confirmed the facility did have a multidisciplinary care plan problem, goal and intervention tool to be used for patients with suicidal ideations and previous suicide attempts.

Interview with S3 RN/BMU Program Director on 2/16/11 at 1:45 p.m. confirmed the patient was admitted for a suicide attempt, and a nursing care plan for injury risk RT suicide attempt was not initiated throughout her stay at the BMU.

2. Review of the chart for patient #7 revealed she was admitted on 2/9/11 and remained on the BMU during the survey. She had diagnoses of Bipolar disorder and psychosis.

Review of the Multidisciplinary Interview and Assessment obtained upon admission revealed the patient's stated reason for admission was "I'm depressed, suicidal, hoping I can go to sleep so it can get out of my head, paranoid, depressed." Further review indicated the precipitating events/stressors leading to admission were depression, anxiety, suicidal thoughts and the patient's verbal admission that she kept the kitchen knives in the shed because she was scared she would hurt herself due to the voices telling her to do so. The At Risk Assessment portion of the form indicated the patient had suicidal thoughts and 2 prior attempts by cutting and hanging herself.

Review of the Physician's Admit Orders dated 2/9/11 at 6:50 p.m. revealed orders for precautionary checks by staff every 15 minutes RT suicide and falls.

Review of the Treatment Plan Problem sheet dated 2/9/11 reflected the following problems were identified for care planning: depressed mood, altered thoughts, risk of injury to self RT seizures, risk of injury to self RT falls, ineffective pain management RT chronic pain and alteration in health maintenance.

Review of the Multidisciplinary Integrated Treatment Plan and care plan problems/goals/intervention dated 2/9/11 revealed no evidence that the patient's risk of suicide was addressed.

Interview with S1 RN on 2/16/11 at 9:55 a.m. revealed the facility did have a specific care plan with problems, goals and interventions RT suicidal ideations/suicide attempts. She confirmed the patient had suicidal ideations, and a care plan for suicide risk should have been initiated.

Interview with S3 RN/BMU Program Director on 2/16/11 at 10:37 a.m. confirmed the facility did have a care plan for injury to self RT suicide ideations, and it should have been initiated upon admission.

3. Review of the chart for patient #2 revealed she was admitted on 1/6/11 with the following presenting signs and symptoms: paranoia, hallucinations, elopement from living situation/housing at a Partial Hospitalization Program. She was diagnosed with schizoaffective disorder.

Review of the Physician's Admit Orders dated 1/6/11 at 3:30 p.m. revealed orders for precautions including every 15 minute checks, elopement and falls.

Review of the Multidisciplinary Integrated Treatment Plan and care plan problems, goals and interventions initiated on 1/6/11 revealed no evidence that the patient's elopement risk had been care planned.

Interview with S3 RN/BMU Program Director on 2/17/11 at 9:45 a.m. revealed the facility did not have a formal care plan for patient elopement. He confirmed the patient had previous elopements and was in need of a care plan. He stated the facility would need to develop one.

4. Review of the record for patient #8 revealed she was admitted to the facility on 2/11/11 with signs and symptoms of nervousness, anxiety, depression, crying, biting herself on the wrist and c/o her boyfriend verbally abusing her. She was diagnosed with Bipolar disorder.

Observation of the patient in the BMU on 2/15/11 at 12:50 p.m. revealed she was slightly unsteady on her feet.

Review of the At Risk for Falls Assessment dated 2/11/11 revealed her fall risk score was 9. According to the form, a score from 5-10 was considered moderate risk for falls, and fall precautions should be initiated.

Review of page 3 of the Multidisciplinary Interview and Assessment completed on 2/11/11 reflected the patient had recent falls.

Review of the Daily Clinical Staffing & Management Report dated 2/15/11 revealed the patient should be on fall precautions.

Review of the care plan problems, goals and interventions revealed no documentation RT to the patient's risk for falls.

Interview with S3 RN/BMU Program Director on 2/16/11 at 3:20 p.m. revealed the patient was at risk for falls, and a care plan for fall precautions should have been initiated upon admission.

Review of the Behavioral Medicine Unit Policies and Procedures for Psychiatric Nursing Service revealed the RN is responsible for gathering information from nursing assessments and doctor's assessments in order to enter active problems on the Problem List, formulate a Treatment Plan and initiate treatment.