HospitalInspections.org

Based on observation, record review and interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans to address presenting problems for 3 of 8 active sample patients (C3, E4 and E6) and one of 14 non-sample patients reviewed (C13) to direct staff in the care of these patients. This failure results in fragmented treatment, without orientation to each patient's goals.

Findings include:

A. Patient C3:

1. Patient C3 was admitted to the facility on 8/29/11 and was placed in mechanical restraints later that day for aggression/violence toward others.

2. Review of the problem on Patient C3's master treatment plan (dated 8/29/11) titled "Risk for Restraints" revealed that this plan included interventions stated as generic, role functions, rather than specific medications and nursing interventions based on individual patient behaviors to prevent and care for the patient if/when aggression reoccurred.

a. Physician interventions included all four generic, role functions on the preprinted form without individualization:
"Assess/adjust medications efficacy during each visit and/or as needed.
Provide directions for use of psychoactive medications to reduce/eliminate the need for (remaining words left off form).
Obtain informed consent for psychoactive medications. prior (sic) to initiating each.
Monitor and educate regarding precautions, risks, benefits, and side effects of medications. during visit (sic)."

b. Nursing interventions included the following generic, role functions without individualization.
"2 group or 1:1 x [blank] days to provide education related to stress/anger management techniques to augment coping skills.
Provide medication education prior to initiation of therapy and as needed during continuations of same each time of each administration.
Use de-escalation techniques to prevent aggression-acting out or violent episodes whenever signs of escalation appear.
Use non-violent crisis intervention techniques (words omitted) less restrictive interventions have been unsuccessful."

B. Patient E4 was a geriatric patient admitted on 8/8/11 with the diagnosis of Alzheimer's dementia with behavioral disturbance.

1. Observations of Patient E4 on 8/31/11 at 10:50a.m. and on 9/1/11 at 1:15p.m. revealed that this patient presented with confusion and impaired memory. Staff constantly followed the patient around the ward, redirecting as needed. During interview on 8/31/11 at 11:30a.m., Patient E4 was unable to answer direct questions, stating "I have to go see about the baby."

2. Review of Patient E4's master treatment plan, dated 8/8/11 with latest revision on 8/26/11, revealed that the plan failed to address this patient's confusion and severe memory impairment.

3. During interview on 9/1/11 at 11:40a.m., Physician 1 verified that Patient E4's confusion and impaired memory were not addressed in the master treatment plan.

C. Patient E6 was a geriatric patient admitted on 8/29/11 with the diagnosis of Alzheimer's dementia with behavioral disturbance.

1. Observations of Patient E6 on 8/31/11 at 10:50a.m. and on 9/1/11 at 1:15p.m. revealed that this patient presented with confusion and impaired memory. During interview on 8/31/11 at 10:55a.m., Patient E6 was able to answer some direct questions, but exhibited confusion and impaired memory.

2. Review of Patient E6's master treatment plan (dated 8/24/11 with latest revision on 8/25/11) revealed that the plan failed to address this patient's confusion and severe memory impairment.

3. During interview on 9/1/11 at 11:40a.m., Physician 1 verified that Patient E4's confusion and impaired memory were not addressed in the master treatment plan.

D. Patient C13 was a young adult involuntarily admitted to the facility on 8/18/11 with a diagnosis of Psychosis NOS.

1. During an observation on 8/31/11 at 10:15am, Patient C13 was lying in bed resting while most other patients (approximately 9) were attending a unit group activity. Patient C13 stated, "I'm tired. My medications knock me out." In an interview on 9/1/11 at 1:45pm, Patient C13 described his/her hospital stay as "I just want to be discharged and go home so I can start college. The problem is I'm so sedated from medication that I can't get to groups. The nurses and doctor said that if I don't take all of my medications then I can't go home, but if I take medication then I get tired and miss groups. When I miss groups they (staff) tell me I'm not involved in treatment so I can't go home. At this point I'll never get out of here." When asked about medications, Patient C13 stated that "the three medicines they give me (Haldol, Ativan and Benadryl together), I get in trouble because I have a loud voice and the nurses don't like it, they just give it (medications) to me to knock me out."

2. Review of Patient C13's Medication Administration Record (MAR) noted that the patient's psychosis was being treated with routine dosing of an antipsychotic. The MAR showed that the patient had received all doses of the antipsychotic since admission. The "PRN Medications" page of the MAR noted that Patient C13 had also been ordered doses of Haldol (sedating antipsychotic) 5 mg q4hrs (every 4 hours) PO/IM (oral/intramuscular) PRN (as needed) psychosis; Ativan (sedating benzodiazepine) 2 mg PO/IM q4hrs PRN agitation/anxiety and Benadryl (sedating antihistamine) 50 mg PO/IM q4hrs PRN EPS (extrapyramidal symptoms). The MAR showed that the patient received dosing of Haldol, Ativan and Benadryl on 8/19/11 (2:30pm); 8/22/11 (1:00pm); 8/27/11 (2:00am); 8/28/11 (1:40am and 12 noon); 8/29/11 (12:15am); 8/30/11 (2:10am and 11:30am); 9/1/11 (9:00am). Patient C13 also received Ativan alone on 8/23/11 (1:30pm); 8/24/11 (3:50am) and 8/25/11 (6:05pm).

3. Review of Group Notes revealed the following:

a. Group Therapy note dated 8/22/11 at 10:00am noted "Patient was sleep in room. Patient did not participate. (sic)"; 8/22/11 at 11:00am noted "Sleeping."; 8/22/11 at 4:15pm noted "Sleeping in room, Patient refused to attend."

b. Group Therapy note dated 8/24/11 at 1:00pm noted "Patient slept through most of the group."

c. Group Therapy note dated 8/25/11 at 1:00pm noted "...Patient left group early stating [s/he] was extremely tired and wanted to lie down."

d. Social Work Group Therapy note dated 8/27/11 at 1:00pm noted "Attended, but did not participate, Sleeping." "Patient stated [his/her] meds are pretty strong, but did want to go lay down."

4. Review of the Master Treatment Plan dated 8/20/11 identified Medication Non-compliance as a problem, although the MAR showed that Patient C13 never refused any medication dosing; but failed to identify patient's sedation and inability to participate in treatment as a problem,

5. During an observation of the Unit C treatment team meeting on 9/1/11 at 9:00am, Patient C13 was discussed. RN1 stated that "[Patient C13] wasn't attending groups because of sedation; [s/he] had been given the cocktail each day (referring to Haldol, Ativan and Benadryl)." The treatment team did not discuss any modification to the treatment plan to address the issue.