HospitalInspections.org

Based on document review, observation, and staff interview, the hospital failed to ensure 4 (S1, S2, S3, and S4) of 4 patients received their diabetic diet as prescribed by a qualified practitioner on 5/26/2015.

Findings included:

1. Options Behavioral Health System Nursing Training Update (dated 1/29/2015) indicated special diets will have a special patient identifier with a blue wrist band and color coded dots on the band that will identify the type of diet the patient shall be on: red - allergy; green - diabetic; blue - mechanical soft; and yellow - pureed. Nurses shall conduct nutritional screen assessments on all patients.

2. Medical Executive Meeting dated 1/29/2015 stated, "Since the potential for nocturnal hypoglycemia in clients with diabetes mellitus type 1 and diabetes mellitus type 2 is great and life threatening it shall be the policy of Options Behavioral Treatment Center to provide a diabetic evening snack for such clients."

3. Week-1 lunch menu was reviewed. A regular meal consisted of 1 square of lasagna, 1/2 cup green beans, 1 slice garlic bread, 4 ounces ice cream, and 8 ounces of choice beverage. The regular meal included 1 after noon and evening snack. The 1500 Cal diabetic diet included everything on the regular meal; however, wheat toast would be substituted for garlic bread; 1/3 cup of green beans substituted for 1/2 cup; and 1/2 cup of chocolate pudding substituted for ice cream. The diabetic meal had an evening snack only. The consistent CHO (carbohydrate) diet was the same as the regular diet but substituting sherbet for ice cream. The diet does not have any snack meals throughout the day.

4. The Dietary Department diet book listed 4 patients in the hospital that were receiving a therapeutic diet (S1, S2, S3, and S4). The diet book listed 3 patients to receive a diabetic diet and 1 patient to receive a mechanical soft diet.

5. Patient medical records were reviewed for the four patients of the hospital: (S1, S2, S3, and S4). The medical records had documented orders by a physician that all four patients were to receive a diabetic diet. Patient S3 was on a mechanical soft diet; however, on 5/20/2015, the patient had a new order for a diabetic diet. All four patients were diabetes type 2.

6. At 12:00 PM on 5/26/2015, the patient tray line was observed in the cafeteria. Patient S2 was observed provided a regular meal and not the diabetic meal as prescribed. The patient's blue wrist band had a green diabetic dot marked diabetic.

7. At 12:20 PM on 5/26/2015, staff member #2 (Food Service Manager) confirmed patient S3 was still receiving a mechanical soft diet because he/she has never received an updated diet order. The staff member confirmed the other three patients (S1, S2, and S3) were receiving a consistent CHO diet and not the approved 1500 Cal diabetic diet. The staff member indicated he/she thought the consistent CHO diet was the same as a 1800 Cal diabetic diet because he/she thought the 1500 Cal diet was to strict. The staff member indicated he/she never contacted the Dietician on this change.

Based on record review and interview, the facility failed to ensure that the Psychosocial Assessments of eight (8) of eight (8) active sample patients (A2, A7, B1, B2, C1, C2, D6 and D7) included the role of the social work staff in treatment and discharge planning. This failure results in no information being provided as the treatment team formulates a comprehensive treatment plan and determines what efforts are being pursued by social service staff.

The findings include:

A.Medical Record Review:

All of the Psychosocial Assessments of the following active sample patients (dates of the Psychosocial Assessments in parenthesis) lacked a description of the anticipated role for the social services staff: A2 (5/15/20), A7 (5/25/15), B1 (5/14/150, B2 (5/2/15), C1 (5/19/15), C2 (5/25/15), D6 (5/13/15), D7 (5/22/15).

B. Staff Interview:

On 5/27/15 at 10:00 a.m., the Director of Social Services was interviewed. The Director was shown the Psychosocial Assessments of Patients A7, B1, B2 and C1. The Director agreed that the role of social service staff in treatment and discharge planning was not included within the assessments.

Based on observation, record review and interview the facility failed to develop Master Treatment Plans for eight (8) of eight (8) active sample patients (A6, A10, A15, B3, B4, B6, C3 and C4) that included individualized treatment interventions with a specific purpose and focus. Many of the interventions on the treatment plans were listed as generic discipline functions/tasks or there was failure to identify interventions based on the patients' needs. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

A. Record Review:

1. Patient A6:

For problem identified as "Aggression with Dementia" in treatment plan dated 1/15/15, the only nursing interventions were listed as expected role functions, "Administer medication as prescribed, assess for adverse side effects and compliance with taking medications." A physician intervention was identified as a nursing intervention, "Prescribe and monitor medications to address: agitation, outbursts and mood stabilization." There were no specific nursing interventions to address the patient's cognitive deficits in the care of this patient in the clinical area.

Medications were not addressed in the treatment plan by the physician.

2. Patient A10:

For problem identified as "Aggression with Dementia" in treatment plan dated 1/15/15, the only nursing interventions were listed as expected role functions, "Administer medication as prescribed, assess for adverse side effects and compliance with taking medications." A physician intervention was identified as a nursing intervention, "Prescribe and monitor medications to address: agitation, outbursts." There were no specific nursing interventions to address the patient's cognitive deficits in the care of this patient in the clinical area.

The social work intervention was not clearly stated. It was written as "Individual therapy to educate patient on perceived benefits of cutting and alternate, more appealing means to those benefits."

Medications were not addressed in the treatment plan by the physician.

3. Patient A15:

In treatment plan written on 1/13/15, for problem identified as "Disturbed Thought Process," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.

4. Patient B3:

In treatment plan written on 12/11/14, for problem identified as "Suicide Risk/Self-Harm Behaviors," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." According to a physicians note on 12/11/14, Patient B3 was "admitted after cutting self...attempted to cut self in this facility which required suturing." There were no specific nursing interventions for patient safety, nor were preventive measures related to self-cutting and suicide risk identified in the plan.

The social work intervention was not clearly stated. It was written as "Individual therapy to educate patient on perceived benefits of cutting and alternate, more appealing means to those benefits."

During interview on 1/20/15 at 9:15 a.m., Patient B3 reported that he/she is currently taking Adderall, Prozac and Lithium. These medications were not addressed by the physician in the treatment plan.

5. Patient B4:

a. In treatment plan written on 1/10/15, for problem identified as "Suicidal Ideations with Attempt," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for patient safety, nor were preventive measures related to suicide risk identified in the plan.

b. In treatment plan written on 1/10/15, for problem identified as "Auditory and Visual Hallucination," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.


6. Patient B6:

In treatment plan written on 11/22/14, for problem identified as "Impaired Memory," the nursing intervention was listed as an expected role function: "Administer medication as prescribed, assess for adverse side effects." Another nursing intervention was incomplete: "Assess patient for: "One listed nursing intervention was a physician role function: "Prescribe and monitor medications to address: Side effects and effectiveness."

There were no identified physician interventions in this treatment plan.

A social work intervention was listed as "Individual therapy to educate patient on: Good morals and behaviors." Meaning of this focus for treatment was not clear. Another social work intervention was incomplete: "Family therapy to educate on:"

7. Patient C3:

In treatment plan written on 12/22/14, for problem identified as "Disturbed Thought Process," the only nursing intervention was listed as an expected role function, "Administer medication as prescribed, assess for adverse side effects." There were no specific nursing interventions for to address this patient's behaviors in the clinical area.

During interview on 1/20/15 at 1:40 p.m., Patient C3 reported, "I am legally blind," This issue was not addressed in the treatment plan by nursing.

8. Patient C4:

In treatment plan written on 1/16/15, for problem identified as "Suicidal Ideation," there were no identified nursing or physician interventions.

B. Interviews:

1. During review of Patients B3 and B6's treatment plans on 1/21/15 at 11:30 AM, NP6 acknowledged that the interventions should be patient specific.

2. During interview with review of treatment plans on 1/21/15 at 1:25 PM, the DON stated related that after an patient assessment was performed by the nurse, the nursing interventions on the plan should be aimed at helping the patient to reach his/her maximum potential in the hospital.







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Based on record review and interview, the facility failed to ensure that the Master Treatment plans (MTPs) addressed specific treatment needs for eight (8) of eight (8) active sample patients (A2, A7, B1, B2, C1, C2, D6 and D7). Instead, interventions on the plans were primarily routine, generic discipline functions inappropriately listed as individualized interventions. In addition, many of the staff intervention on the treatment plans provided identical treatment measures for different patients regardless of the identified problem(s). These deficiencies result in a lack of guidance for staff in providing individualized patient treatment that was purposeful and goal directed.

Findings include:

A. Medical Records

1. Facility policy number PC 8.06, titled "Master Treatment Planning," last reviewed 1/15/15, stated: "The MTP shall detail specific services to be delivered." This was the only statement in the policy that related to the nature of the interventions. Most of the generic interventions cited below did not include specific individualized behaviors or needs for each patient.

2. Active sample patient A2, MTP dated 5/22/15

For the problem of "suicidal ideation":

The physician interventions were: "Physician/LIP [licensed Independent Practitioner] to assess mood, mental status, presence of internal stimuli, presence of suicidal ideation, presence of homicidal ideation, effectiveness of medication."

The nursing interventions were: "Nursing to assess mood, behavioral status, patient's perception of medication effectiveness; psych education groups to facilitate identification of distorted, unrealistic thoughts and beliefs; assist with ADL's [Activities of Daily Living] to improve routines of self-care, proper diet."

Social services interventions were "provide recreational activities to allow [him/her] to express [him/herself] creatively and engage in activities/exercise to improve [his/her] health; Process groups to facilitate peer support and rapport, healthy emotional expression and positive self-talk."

3. Active sample patient A7, MTP, dated 5/22/15

For the problem "suicidal ideation":

The physician interventions were: "Physician/LIP [licensed Independent Practitioner] to assess mood, mental status, presence of internal stimuli, presence of suicidal ideation, presence of homicidal ideation, effectiveness of medication."

The nursing interventions were: "nursing to assess mood, behavioral status, patient's perception of medication effectiveness; psych education groups to facilitate identification of distorted, unrealistic thoughts and beliefs; assist with ADL's [Activities of Daily Living] to improve routines of self-care, proper diet."

Social services interventions were: "provide recreational activities to allow [him/her] to express [him/herself] creatively and engage in activities/exercise to improve [his/her] health; Process groups to facilitate peer support and rapport, healthy emotional expression and positive self-talk."

For the problem of homicidal ideation:

The physician/LIP interventions were: "Assess mood, mental status, presence of suicidal ideation, effectiveness of medication."

The nursing interventions were: "Nursing to assess mood, behavioral status, patient perception of medication effectiveness; psych education groups to facilitate identification of distorted/ unrealistic thoughts and beliefs; assist with ADL's to improve routines of self-care, proper diet."

The social services interventions were: "Provide non-threatening, supervised opportunity to encourage peer intervention in group sessions including: activities patient can do to help stay healthy; process groups to facilitate peer support and rapport, healthy emotional expression, positive self-talk."

The staff interventions listed above for the problems of suicidal and homicidal ideations were similar or identical in content. Neither focused on the specific problems of each patient.

4. Active sample patient B1, MTP, dated 5/26/15

For the problem of "aggression":

The generic physician intervention was: "Monitor and adjust medication to address liability of mood and impulsivity to aggressive behavior, assess mental status."

The nursing interventions were: "Administer medication and monitor for changes in mental status and side effects, assess mental and behavioral status; Assist with ADLs to establish and maintain roles and structure, facilitate psych-ed groups to identify triggers and coping skills of aggression."

Generic social services interventions were: "Facilitate process groups to establish peer support and sense of belonging, practice safe emotional expression, and receive insight and prospective from peers and staff. Facilitate family session to identify successful redirections/interventions, build behavioral safety plan and discuss discharge planning and community supports."

The activity therapy intervention was "Provide activity therapy to explore calming activities, form new coping skills, and safely practice effective interpersonal skills.

For the problem of "psychosis":

The physician intervention was "Monitor and adjust medication as necessary to address auditory hallucinations and biochemical imbalances leading to psychosis."

The nursing interventions were: "Administer prescribed medicine; monitor for internal stimuli and changes in behavioral/mental status; assist with ADLs and following rules/structure of milieu; facilitate psych-ed groups to understand triggers and how redirections work."

The social services interventions were: "Facilitate process groups to gain peer support; learn to discuss emotions and stressors safely, and gain insight/prospective from others; facilitate family therapy sessions to discuss discharge planning, aftercare, and building a behavioral plan for home to build structural supports."

The activity therapy intervention was "Provide activities therapy to redirect client focus to calming and enjoyable activities, practice effective interpersonal skills and creative expression."

Again, the interventions were worded about the same for the 2 different problems listed above and did not go into specific details to address the aggressive behavior versus the psychotic behavior. Both were being addressed in the same way.

5. Active sample patient B2, MTP, dated 5/4/15

For the problem of "aggressive behavioral":

The physician interventions were: "Physician/LIP to assess: (circle applicable) mood - mental status - presence of internal stimuli - presence of SI - presence of HI - effectiveness of medication." None of the choices were circled.

The nursing interventions were: "Nursing to assess (circle applicable) mood - behavioral status - hygiene status - presence of internal stimuli - orientation - appetite - sleep pattern - interaction on unit - presence of SI - presence of HI - patient perception of medication effectiveness." None of the choices were circled.

"Psych education groups to facilitate coping skills for aggression, improved communication skills; assist with ADL's to improve communication skills."

6. Active sample patient C1, MTP, dated 5/20/15

For the problem of "depression w[with]/suicidality"

The physician interventions were: "Monitor and adjust medication as necessary to address depressive symptoms; assess mental status and screen for current risk of suicide and improvements to mood."

The nursing interventions were: "Administer medication and monitor for side effects; assess mental and behavioral status on unit and screen for patient's perceptions of mood and effectiveness of current treatments; ensure milieu staff maintains unit schedule and structure; assist with ADLs, and provide psych-ed groups to understand pattern of thought and develop more effective coping skills."

The activity therapy was: "Provide enjoyable activities to encourage self-expression; promote relaxation, and discuss new activities to utilize in stress management."

The social services intervention was: "Facilitate individual family session to discuss discharge and aftercare."

The interventions for active sample patient C1 were generic and did not identify or focus on the specific problems and needs this patient showed.

7. Active sample patient C2, MTP, dated 5/25/15

For the problem of "suicidality":

The physician intervention was: "Monitor and adjust medication as necessary to address symptoms of anxiety as they arise; assess mental status and screen for rise of harm to self or to others; assess effectiveness of medication."

The nursing interventions were: "Administer medication and monitor for side effects; assess mental and behavioral status on the unit and screen for patient's perceptions of improvement and medication effectiveness; lead milieu staff to maintain unit schedule and structure; assist with ADL's, and provide psych-education groups and activities to explore unhealthy patterns and develop more efficient coping skills."

A social services intervention was: "Facilitate individual or family session as deemed necessary to discuss safety planning discharge and aftercare."

The activity therapy intervention was: "Provide calming and enjoyable activities to encourage self-expression, promote relaxation, and discover new activities to utilize in stress management."

8. Active sample patient D6, MTP, dated 5/13/15

For the problem of "depressed mood with S.I."

The physician intervention was: "Assess mood, mental status, presence of S.I., and effectiveness of medication."

The nursing interventions were: "Assess mood, interaction on unit and behavioral status, pt.'s [patient's] perception of medication effectiveness; psych education groups to facilitate ways to cope with sx [symptoms] of depression; assist with ADL's to improve self-esteem and general hygiene."

The activity therapy intervention was: "Provide supervised opportunity to encourage peer interaction in group sessions, including ways to improve mood."

The social services interventions were: "Reminiscent groups to facilitate remembering happy times; family involvement to discuss progress, treatment, symptoms, meds & [medications and] discharge planning."


9. Active sample patient D7, MTP, dated 5/22/15

For the problem of "psychosis":

The physician's intervention was: "Physician will assess [name of patient] mood, mental status, presence of internal stimuli and effectiveness of medication."

The nursing interventions were: "Nursing will assess[his/her] mood, behavioral, interaction on the unit, presence of internal stimuli, orientation, and medication effectiveness; assist with ADLs to improve hygiene, working with others and reducing paranoid delusions."

Social services interventions were: " Reminiscent therapy to reminisce about past times and improve mood; conversation to discuss any symptoms, progress, treatment and discharge planning."

For the problem of "aggression/agitation"

The physician intervention was: "Physician will discuss [name of patient] mood, mental status and effectiveness of medication."

The nursing interventions were: "Nurse will assess [his/her] mood, behavior, interaction on unit, orientation and medication effectiveness; psych education group to learn appropriate ways to interact with staff and peers without aggression."

Social services interventions were: "Reminiscent group to improve mood; POA conversation to discuss symptoms, treatment, progress & [and] discharge planning."

Activity therapy intervention was: "Activity therapy group to practice expressive activities to reduce aggression."

The interventions for D7's 2 different identified problems were almost identical.

None of the interventions for active sample patients C2, D6 and D7 spelled out specific behaviors and needs each one exhibited. As with the other interventions for other patients above, generic discipline approaches were listed without zeroing in on each patient's specific problems and needs.

B. Interviews

1. In an interview on 5/27/15 at 9:15 a.m., the generic and similar interventions, in many instances, on the Master Treatment Plans, regardless of each patient's different problems and needs, were discussed with the Director of Social Services. She did not dispute the findings. "What we are going to have to do is make [interventions] more specific by including specific behaviors."

2. In an interview on 5/27/15 at 2:30 p.m., the generic nursing interventions were discussed with the Nursing Director. He, too, did not dispute the findings. This is a work in progress.