HospitalInspections.org

Based on record review and interview, the facility failed to promote respect and dignity for patients as evidenced by:
Patient bedroom doors were locked during the day and the patients had to use the one public bathroom behind the nurse's station.

Findings include:

Interview on 7/8/14 at 10:00 a.m. with Patient #19 on 500 unit, she said she thought it was "silly" not to be able to use the bathroom in her own room. She said 24 people had to use one bathroom; both men and women. She said she felt uncomfortable using a bathroom after a male. She said they wet the seat and the men were uncomfortable because the women left the seat down.

Interview on 7/8/14 at 10:30 a.m. with RN #60 on the 300 unit, he was asked about why the patients had to use the same bathroom. He said the bedroom doors were kept locked during the day to keep patients from staying in their room all day and it was hard to monitor what they were doing. He said the facility was trying to weigh the patient's dignity with trying to keep them safe. He said that if a patient wanted to use their own bathroom they just had to ask staff and they would unlock the door.

Interview on 7/10/14 at 10:20 a.m. with Patient #15 on 400 unit, he said, "I have to always use the bathroom behind the nurses' station during the day, because our rooms are kept locked. If I ask to use the bathroom in my room it depends on the staff member if they will allow you to use your room's bathroom. some staff are nice about it and others are not. The bathroom behind the nurses' station always has pee all over the commode seat."

Interview on 7/10/14 at 10:30 a.m. with Patient #21 on 400 unit, she said that during the day the patients were told to use the bathroom behind the nurses' station. She said, "I did not know that we could request to use the bathroom in our room."

Record review of the facility's Infection Control log for March 2014 revealed 13 episodes of gastroenteritis from 3/4/14 to 3/12/14.

Record review of the investigation report by the prior Infection Control Nurse, RN #87, revealed the following:
"This is the effects of a cluster of Gastro Infections on units 500/700. When researching the data my findings indicated that the virus came from one newly admitted patient and progressed throughout 500 and 700 units. One direct result of this could be that patients were being herded into one bathroom. And the virus became out of control before nursing began opening doors for patient so (to) use their own restrooms."

Interview on 7/10/14 at 3:00 p.m. with CEO (Chief Executive Officer) #50, he said that when he came to the facility, he made the decision to keep the doors to the bedrooms locked during the day in order to get the patients to participate in activities. He said that most of the patients would just stay in bed all day if they could. He said the original idea was for the doors to be opened at specific times during the day to use the bathroom, like smoke breaks. He said the one public bathroom behind the nurses' station was to be used in an emergency or as a closer place to use the bathroom when the patient was in group. When he was informed that patients were complaining that they could not use their own bathrooms because staff would not open the doors, he said he guessed he would have to re-inservice staff about letting patients use their own bathrooms and to set up specific times to open the doors. When he was asked about the result of the investigation in March 2014 of the gastroenteritis outbreak, he said the public bathrooms were cleaned twice a day by housekeeping staff.

Based on record review and interview the
hospital failed to conduct performance
improvement projects in 2013 and 2014. The
hospital failed to document what quality
improvement projects were being conducted, the
reason for conducting these projects, and the
measurable progress achieved on these projects.
Findings include:
Record review of Medical Executive / Quality
Assurance meeting minutes in 2013 an 2014
revealed no documentation of what quality
improvement projects were being conducted.
The Chief Operating Officer (COO) / Quality
Assurance Director (ID# 52) stated on 7/10/14, at
2:30 p.m., that the hospital has a committee titled
"Failure Mode, Effects, and Criticality Analysis
Admission and Assessment Process, (FMEA)."
The COO stated that the functions of the
committee include Quality Improvement projects.
The COO stated that currently the hospital is
conducting 3 (three) Quality Assurance projects:
1) Inadequate Triage, 2) Extended wait time,
and 3) Patients feeling ignored.
Record review of the meeting minutes for the
FMEA meetings revealed the above listed
projects have been ongoing since 2012. One
meeting (no date) stated the "Target Date" was
April 30, 2012, for the three projects: Inadequate
Triage, Extended Wait Time, and Patient Feeling
Ignored.
Record review of a FMEA meeting dated
11/13/13, stated "It was agreed that the
committee will meet monthly immediately
following patient safety counsel." The next
FMEA meeting documented was dated 4/9/14.
The committee continued to focus on 1)
Inadequate Triage, 2) Extended Wait Time, and
3) Patient feeling ignored.
The Quality Assurance Director stated on 7/11/14
, at 1:40 p.m., that the only FMEA meeting held in
2014 was held 4/9/14, and the performance
improvement projects remained the same as
previous meetings / years.
Record review of the hospital's "Performance
Improvement Plan" dated 2014 revealed the plan
failed to address the need for distinct
improvement projects to be held annually.

Based on record review and interview the Hospital failed to ensure that one Advanced Nurse Practitioner's (ID# 75) application for staff was correct and failed to ensure two (2) of three Advanced Nurse Practitioners reviewed had three peer references according to their Bylaws.
(Advanced Nurse Practitioners: #74 and #75)

Findings include:

Record review of the credential file for Advanced Nurse Practitioner ANP - ID# 75 revealed a Data Bank Process Data sheet dated 6/5/12 stated "Type of Adverse Actions = Licensure; Basis for Action = Criminal Conviction; Reporting Entity = Texas Board of Nursing; Order = Remedial Education."

Disclosure question # 13 on the application asked "To your knowledge, has information pertaining to you ever been reported to the National Data Bank. The nurse practitioner answered "No."

Disclosure question # 14 on the application asked "Have you ever been investigated, sanctioned, reprimanded or cautioned by a military hospital, facility, or agency...." The nurse practitioner answered "No."

Interview 7/9/15 at 10 a.m. with the employee responsible (ID# 64) for credentialing revealed she was not aware that question #'s 13 and #14 were answered incorrectly on the application for Nurse Practitioner ID# 75.

Record review of the credential file dated 4/13/13 for Nurse Practitioner ID# 75 revealed the file only had two peer references.

Record review of the credential file dated 11/21/13 for Nurse Practitioner ID# 74 revealed the file only had two peer references.

Record review of "Medical Staff Bylaws" dated 6/26/14 stated under "Procedures for Appointment - References: the names of at least three practitioners...who are able to provide knowledgeable peer recommendations..."

The staff member (ID# 64) responsible for credentialing acknowledged that the files for Nurse Practitioner ID# 's 74 and 75 only had two peer references.

Based on record review and interview, the facility did not have an Advisory Committee as evidenced by:
-The DON stated the facility did not have an Advisory Committee.
-The Staffing Plan was a grid that did not address acuity or need for one to one monitoring
-The Staffing Plan was dated 2010 and the facility did not have any documentation of revisions to the plan.
-The facility did not offer a way for nursing staff to write concerns or to be informed of how their concerns were addressed.
-Per staffing schedules there were shortages of RNs and LVNs, but these deviations were not assessed or addressed.
-Semiannual reports were not presented to the governing board showing deviations from the Nursing Plan.

Findings include:

Interview on 7/8/14 with a RN (Registered Nurse) who wished to remain anonymous revealed when the census was low, one RN would cover two units on occasion.

Interview on 7/10/14 at 2:00 p.m. with DON (Director of Nursing) #51, she said she became the DON on 9/1/13. She said that prior to that she was the interim DON and the facility did not have an Advisory Committee. She said the facility was still trying to form an Advisory Committee, but was unable to get the RNs (Registered Nurses) and LVNs (Licensed Vocational Nurses) to join the committee. She said the Staffing Plan was by a staffing grid that showed the number of patients at the top and which staff could be used down the column. She said they did not have a formal written way for nurses to express concerns, but the staff would come to her and tell her of their concerns. She said the charge nurses could contact the floating supervisor, who could make determination to call in more staff, if the charge nurse felt the acuity or need for one to one monitoring was needed.

Record review of the facility's Nurse Staffing Grid dated 10/19/12 revealed it did not address acuity of patients only number of patients and daily available hours.

Record review of the facility's Staffing Schedules for 17 random dates from 4/2014 to 7/2014 against the Nurse Staffing Plan which had one RN and one LVN to be scheduled on every 12 hour shift on every unit for any number of patients revealed the following:
4/1/14 on 7p to 7a shift - no LVN for 600 unit
4/3/14 on 7p to 7a shift - no LVN for 100, 400 unit
4/12/14 on 7a to 7p shift - no RN supervisor listed
7p to 7a shift - no RN for 400 unit
4/29/14 on 7p to 7a shift - no LVN on 600 unit
5/10/14 on 7a to 7p shift - no RN for 300 unit
5/21/14 on 7p to 7a shift - no LVN for 400 unit
6/6/14 on 7a to 7p shift - no LVN for 300 unit
7p to 7a shift - no LVNs for 300, 600 units
6/11/14 on 7a to 7p shift - no RN for 600 unit, no LVN for 300 unit
6/12/14 on 7p to 7a shift - no LVNs for 100, 200 or 600 units
6/20/14 on 7a to 7p shift - no LVNs for 400, 600 or 700 units
7p to 7a shift - no RNs for 600 or 700 units, no LVN for 600 unit
6/25/14 on 7 a to 7p shift - no RN for 400 unit
7/3/14 on 7a to 7p shift - no LVNs for 600 and 400 units
7p to 7a shift - no LVNs for units 200, 600 and 700

Per the staffing grid, only MHT were added as the number of patients increased. MHTs are not qualified to give medications.

Interview on 7/9/14 at 3:00 p.m. with RN #81, she said she had been on the Advisory Committee once as the committee chair. She said she served for over one year and the committee was not able to get a quorum. She said they had 10 nurses on the committee. She said that if she had any concerns about acuity of patients or the need for one to one monitoring, she would go to the supervisor. She said if the census was low, two RNs would share a LVN who passed the medications.

Interview on 7/9/14 at 3:10 p.m. with RN #80, she said she had worked at the facility for 5 ? years. She said she had been approached about being on the Advisory Committee and had told them she would be on the committee. She said if she had any staffing concerns as a relief supervisor, she would call the staffing coordinator or the weekend supervisor. She said the facility did an annual employee satisfaction survey on staffing for any concerns.

Interview on 7/11/14 at 8:20 a.m. with DON #51, she said she had a problem getting 5 nurses to be on the committee. She said she had heard that the past Advisory Committee had 10 nurses. She said the policy and procedure for the Advisory Committee did not address how many nurses had to be on the committee. She was asked about the Nurse staffing plan and being short RNs and LVNs. She said that the LVNs usually gave the medications. She said that when they were short a LVN on the 7p to 7a shift, they would schedule a MHT to work and either the RN or a LVN from another unit would pass the medications. She said they had a floating RN nurse supervisor who could cover a unit if they were short a RN. She said the staffing sheets did not always show if someone was called in to cover the shortage. She said she would have to look at the pay sheets to see who was at work on those days.

Record review of the facility ' s Nursing Staffing Advisory Committee policy (no date)revealed the following:
" Policy Statement
The purpose of the Nursing Staffing Advisory committee is to provide a mechanism for nurses to promote nursing excellence and improve nursing practice through staffing advisory. (The facility) standing Nursing Staffing Advisory Committee will have direct input to the hospitals governing board on staffing issues ...."
The standing committee would -
-Be made up of 100% direct care nurses-Meet at least quarterly
-Have an agenda and meeting minutes
-Develop and recommend a nurse staffing plan
-Review, assess and respond to staffing concerns expressed to the committee
-Evaluate, at least semiannually, the effectiveness of the official staffing plan and actual staffing
-Submit to the hospital's governing board at least semiannually a report on nurse staffing and patient care outcomes including the committee ' s evaluation of the effectiveness of the official nurse services staffing plan and aggregate a variation between the staffing plan and the actual staffing
-Develop a staffing plan which had flexibility and provide for contingencies when patient needs and nursing resources change.
-Solicit and consider staffing concerns and communicate in writing, to the nursing staff member who raised the concern, the decision reached by the committee.

Based on record review and interview the Hospital failed to ensure 1 of 7 closed medical records were complete. (The record lacked a physician discharge order and lacked a physician order for the discontinuation of one to one suicide precautions prior to discharge) Patient ID# 16

Findings include:

Medical record review of the chart for Patient ID# 16 revealed the patient was voluntarily admitted 6/30/14. A "Pre-Admission Exam" dated 6/30/14 at 17:11 stated "14-year-old female bought into Kingwood Pines hospital by Foster Mother. Foster Mother reports patient broke up with her boyfriend yesterday and ran away from the home. Patient reports she told her boyfriend one week ago that she would kill herself. Foster Mother reports she found text messages last night that were sent yesterday to patient's boyfriend from patient stating that she would kill herself. Foster Mother concerned for patient's safety....Suicide ideation, patient refused to divulge a plan at this time...Per MD: 14- year- old- female presents with depression, mood swings, aggression and suicide ideation.."

Record review physician admit orders dated 6/30/14 at 17:27 stated "Admit inpatient psychiatric unit. Bipolar.......Precautions: Suicide, Assaultive....Level of observation: every 15 minutes."

Another physician order written 7/2/14 at 16:40 stated "one to one while in room or bathroom." This physician order was renewed 7/3, 7/4, 7/5, 7/6, 7/7, 7/8.

A physician order dated 7/8/14 at 6 p.m. stated "Registered Nurse to call me at 7 a.m., no guns in house, safety plan prior to discharge, Mother to give patient medications, follow-up as per child protective services..."

The nursing notes dated 7/9/14 revealed no documentation that the physician was notified 7/9/14 at
7 a.m. as per the physician order.

Per telephone interview 7/11/14 at 11 a.m. with nurse ID# 85 revealed she was caring for patient ID # 16 on 7/9/14 at 7 a.m. Nurse ID# 85 stated she did call the patient's doctor on 7/9/14 at 7 a.m. to report the patient was "fine" but she failed to document the telephone call in the nursing notes.

Per the nursing notes dated 7/8/14 at 12:32 "Patient discharged home to Mother per Doctor....Patient denies suicidal or homicidal ideation's. Patient mood is stable...." Interview 7/11/14 at 10:30 a.m. with Nurse ID# 87 revealed he made a mistake on the date of this nursing note. The nursing note should have been dated 7/9/14.

Record review of physician orders on 7/9/14 revealed no physician order to discharge patient ID # 16 home. Further review of the physician orders revealed no physician order to discontinue the one to one suicide precautions.

Interview 7/11/14 at 10:30 a.m. with nurse ID# 87 revealed he was caring for patient ID# 16 on 7/9/14 during the 7 a.m. to 7 p.m. shift. Nurse ID# 87 stated he did receive a verbal telephone order from the physician to discharge patient ID# 16 but he forgot to write the physician order.

Record review of a nursing "suicide reassessment" form dated 7/9/14 revealed the section titled "Pre-Discharge Assessment Only" was blank (not completed).

Record review 7/11/14 of a document titled "Physician's Evaluation of Risk at Time of Discharge From Inpatient Care" for patient ID# 16 revealed the form was blank (not completed) and not signed and dated by a physician.

Interview 7/11/14 at 10:25 a.m. with the primary care physician (ID# 86) caring for patient ID# 16 revealed: On 7/9/14 she telephoned the unit and spoke with a Registered Nurse. The nurse reported the patient was not suicidal so the physician gave a verbal order to discharge the patient. The physician made hospital rounds on the afternoon of 7/9/14 but patient ID# 9 had already been discharged.

Record review of a policy titled "Patient Discharge" dated 6/2014 stated 2) "A patient who is a voluntary admission may be discharged for the following reason: a.) Order of the attending physician. 13) The attending physician shall write the discharge order..."

Record review of a policy titled "Medical Record Content" dated 3/2013 stated "Policy: The medical record is a critical medicolegal document which must be compiled accurately, concisely, and in a timely basis.....12.) Physician's Order: If these orders are taken verbally, or by telephone by someone other than the physician, they must be authenticated, timed and dated within 24 hours.....Every order must be signed by a physician...."

Based on observation, record review, and interview, the facility failed to develop a system for identifying and controlling infections as evidenced by:

-The kitchen had multiple areas and equipment that had a thick accumulation of grease and grime by sight and touch.
-Cutting boards were not being used in a sanitary manner per facility policy.
-Food was served off temperature for a breakfast meal. Dietary Aide #55 did not know what the holding temperature should be.
-Food to be served cold was not kept at the proper temperature.
-There were no trash cans at the hand washing sinks.
-Cook #57 did not perform hand hygiene at appropriate times.
-Immunizations were not given or offered to 9 of 11 staff (RNs (Registered Nurses) #81 & 58, LVNs (Licensed Vocational Nurses) #66 & 62, MHTs (Mental Health Technicians) #61 and 78, Cook #54, Dietary Aide #55 and Dietary Manager #53) as per facility policy and procedure.

Findings include:

Kitchen

Observation on 7/8/14 at 9:35 a.m., during the initial tour, revealed the following:
-In the dry storage pantry there was an accumulation of discolored, cloudy liquid in the corner of the room under a wire rack. There was an accumulation of trash, debris and grime under all the wire racks toward the back of the racks.
-The flour storage bin had an accumulation of grime and debris by sight and touch.
-Three gray two tiered carts had an accumulation of grime and grease by sight and touch.
-In the second dry storage pantry there were 4 wire racks without a splash shield on the bottom shelves.
A plastic bin with bags of pasta on a bottom shelf had an accumulation of grime and grease inside and outside by touch and sight. There was a dead bug inside the bin.
-The warming unit had a water pan with a thick accumulation of lime scale and debris. The bottom of
the unit was dirty with grease and grime by sight and touch.
-The frying unit, the stove and the convection oven had a layer of grease and grime to sight and touch
-The back splash to the stove and the griddle had an accumulation of black burnt on grease.
-The steamer unit had an accumulation of grease and grime by sight and touch. The water supply basin had brown discolored water.
-The storage shelf under the prep table had an accumulation of grime to sight and touch.
-Three of five water pans on the steam table had a thick accumulation of lime scale. The steam table was missing a control knob for one of the heating units.
-The cooler by the steam table had a dirty lower shelf to sight and touch.

Interview at this time with DM #53, he was asked if he had enough help to get the work done in the kitchen. He said he could always use more people. He said that he had a cook and a dietary aide (DA) on the day shift. He said the two evening staff, one cook and DA, came in at 10:00 a.m. and left at 6:30 or 7:00 p.m. He was asked for his cleaning schedule.

Record review of the facility's Policy and Procedure for Cleaning List dated 5/25/05 and revised on 7/9/14 revealed the following:
" Purpose: The primary purpose of a cleaning list is to reduce the amount of bacteria. This is necessary to prevent food spoilage and reduce health hazards and to help control odors ....
Procedure:
1. All food preparation equipment and utensils may be contaminated with bacteria capable of producing disease and, therefore, this equipment constitutes a potential public health hazard. Through cleaning and proper sanitizing you can reduce the amount of bacteria ...
3. A cleaning list will be used to document equipment that has been cleaned. This list is divided in to [sic] two groups. Daily cleaning and equipment cleaning. Equipment needs to be cleaned on a routine basis and also as needed.
Record review of the June 2014 cleaning list revealed on the first page were listed the heavier equipment with no dates across the top of the list. The first column had dates from 6/1 - 6/14 and the second column had dates from 6/19 to 6/28. The second sheet was labeled Monday through Sunday on the top and dated from 6/12 to 6/18. There were check marks to show items were cleaned. The third, fourth and fifth pages were dated from 6/9 to 6/15, 6/16 to 6/22 and 6/23 to 6/29 with initials instead of check marks. Several items were left blank on the fourth and fifth pages.

Record review of the July 2014 cleaning list revealed on the first page only the bottom of the convection oven, the fryer, the ice machine, utensil bins and drawers and the dishroom walls had been cleaned on either 7/1, 7/4 or 7/5. Most of the equipment mentioned above had not been cleaned since early to mid June.

Observation at this time revealed several different colored cutting boards on the prep table.
Interview at this time with DM (Dietary Manager) #53, he said different types of food are to be cut on different colored boards. He said he did not have the list of the colored board and which food was to be cut on that board listed on the wall for staff to use.

Interview at this time with Cook #54, she was asked how she used the cutting boards. She said she did not know that certain foods were to be cut on certain colored boards. She said she used all the boards for everything.

Record review of the facility's Policy and Procedure for Use of Cutting Boards dated 5/25/05 and revised on 7/9/14 revealed the following:
" Purpose: To insure proper use of cutting boards
Procedure: ...
3. Cutting boards are designed for specific uses by color as follows.
a. Red cutting board
i. For cutting and portioning raw meat
b. Yellow cutting board
i. For cutting and portioning raw chicken
c. Tan cutting board
i. For cutting and portioning raw fish & seafood
d. Green cutting board
i. For cutting and portioning fruits & vegetables
e. Blue cutting board
i. For cutting and portioning cooked foods
f. White cutting board
i. For cutting and portioning dairy products ..."


Observation at this time of the food temperature log by the steam table revealed at breakfast the gravy was at 129 degrees F (Fahrenheit).

Interview at this time with DM #53 he said the temperature should have been at 135 degrees F. Interview with DA #55, he said he took the temperatures for the food on the steam table that morning. He said he had only been working at the facility for 3 weeks and did not know what the holding temperature was. DM #53 showed him at the bottom of the log there was a statement that if the food was not at 135 degrees F it should be reheated to 165 degrees F.

Record review of the facility's Policy and Procedure for Food Temperature Record dated 5/25/05 and revised on 7/9/14 revealed the following:
"Procedure:
1. The incorrect control of food temperature can contribute directly to the outbreak of food-borne disease ....
4. If temperatures are not in the appropriate range, take steps to correct the problem and notify the Food Service Director. Hot foods should be held at 135' (degrees) F and cold foods below 41' F. Hot foods below 135' F will be reheated to 165' F before serving ..."

Observation on 7/8/14 at 11:30 a.m. revealed 15 cups of fruit cocktail were on a tray at the tray line without being on ice. A second tray of 31 covered, stacked cups of fruit cocktail were on the top shelf without being on ice.

Interview at this time with the DM, he said the fruit was to be served cold. The temperature of the fruit at this time was at 44 degrees F. He said the fruit should be at 41 degrees F.

Observation on 7/8/14 at 11:50 a.m. revealed Cook #57 was cleaning pots and pans in the dirty dish area. He reached around the dish machine and pulled out a sanitized tray of utensils without washing his hands.

There were no trash cans by the three handwashing sinks that were not adjacent to each other. Observation at this time revealed Cook #57 left the dirty dish area without washing his hands. He walked to a hand washing sink outside the dish cleaning area, washed his hands, then carried the paper towel across the kitchen to the large trash can. He was seen two other times leaving the dirty dish cleaning area, go to a sink and get paper towels to wipe his face, open the door to another room, leave that room and them wash his hands.

Record review of the facility's Policy and Procedure for Dishwashing dated 5/25/05 and revised on 7/9/14 revealed the following:
"Procedure: ...
f. When leaving dirty side to clean side wash hands before pulling clean dishes ..."

Record review of the facility's Policy and procedure for Hand washing dated 5/25/05 and revised on 7/9/14 revealed the following:
"Purpose: To prevent cross-contamination ....
Procedure:
1. When to wash hands ...
b. After handling soiled articles
c. After washing dishes ..."

Record review of the Texas Food Establishment Rules dated September 2006 revealed the following:
"229.166(1)(7)(C)
If disposable towels are used at handwashing lavatories, a waste receptacle shall be located at each lavatory or group of adjacent lavatories."

Immunizations

Record review of the facility ' s Policy and Procedure for Mandatory Influenza Vaccination dated 10/2013 and revised on 4/2014 revealed the following:
"Policy:
All employees of (facility) and Licensed Independent Practitioners (LIP) who provide care, treatment or services at the facility, shall be offered the influenza vaccine during the annual influenza vaccination campaign."

Record review of the facility's Policy and Procedure for Employee Immunizations revised on 10/2013 revealed the following:
" Hepatitis B: ...
8. The vaccine is available at no cost to all employees who have occupational exposure to blood borne pathogens ...
10. Employees whose job responsibilities include potential exposure to blood borne pathogens will be offered immunizations with hepatitis B vaccine on a voluntary basis.
11. The second and third doses shall be given at one and six months after the first ..."

Record review of the facility's Policy and Procedure for TB Exposure Control Plan revised on 10/2011 revealed the following:
"B. Replacement Tuberculosis Assessment
1. ALL HCW ' s (health care workers) will be assessed and screened for TB infection or disease before employment. ...
C. Annual TB Skin Testing
1. Annual tuberculosis infection or disease assessment will be performed on all HCW ' s and volunteers every year. All HCW ' s will be required to complete a health/TB questionnaire annually ....
4. HCW ' s with a documented past history of a reactive positive TSTS (Tuberculin Skin Tests) .... These HCW ' s will be required to maintain a normal chest x-ray with results maintained in Employee Health."

Record review of 11 personnel immunization files revealed 9 did not receive the following:
RN #81 - Date of Hire (DOH) 7/14/10. Last TB screen 7/14/10. Order for chest x-ray, but no results in file. No flu offered.
RN #58 - DOH 1/26/05. No Hepatitis (Hep) B offered
LVN #66 - DOH 5/14/12. No flu offered, TB test last given on 5/15/12 and no TB assessment
LVN #62 - DOH 8/19/13. TB screen not dated. No flu offered. Hep B consent was signed, but Hep B was not given.
MHT (Mental Health Tech) #61 - DOH 3/4/13. TB screen not dated. Hep B information form blank and no flu offered.
MHT #78 - DOH 5/6/13. No flu offered. Hep B consent was signed, but Hep B was not given.
Cook #54 - DOH 10/5/14. No flu offered, TB test last given on 10/14/12 and no TB assessment
Dietary Aide #55 - DOH 6/9/14. TB screen not signed or dated. No flu or Hep B offered.
Dietary Manager #53 - DOH 9/23/13. TB screen and Hep B information forms were blank

Interview on 7/11/14 at 1:55 p.m. with DON #51, she said the facility had a Skills Competency Fair in 9/2013 and the flu "declanation" was offered to all staff. She said she did not know where those declanations were put. She said that when she became DON on 9/1/13 the policy and procedure for TB was to give every 5 years. She said that was changed some time in 2014 to annually. She said it should be in some meeting minutes. She said that Hep B should be offered. She left to check the minutes. She came back about 15 minutes later and said she could not find the meeting minutes that addressed changing the TB test from 5 years to 1 year. She acknowledged that the policy and procedure given was revised 10/2011 and stated to give TB annually. She said the revised date did not get changed.

I. The facility failed to monitor a discharge of minor female patient (Patient R4) in a safe manner resulting in an immediate jeopardy. (Refer to B125)

II. In addition the facility also failed to:

1. Develop and document individualized treatment interventions, including treatment focus, based on the patients' needs for six (6) of eight (8) active sample patients (R1, R2, R3, R4, L5, and L7). This resulted in failure to provide a basis for accurate implementation, evaluation and revision of treatment plans based on patients' responses to treatment. (Refer to B122)

2. Provide alternative programming/activities for patients who are too acutely ill or refuse to attend scheduled programming activities. A treatment plan not updated when a patient's clinical condition changes. In addition, physician's signatures missing on four (4) of eight (8) treatment plans. (Refer to B125)

Based on record review and staff interviews, the facility failed to ensure that the social service assessments included individual patient's strengths and individualized recommendations for social work services from the data gathered for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, L7, and L8)). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams.

Findings include:

A. Record Review

1. Patient R1 was admitted on 07/04/14. The psychosocial assessment, done on 07/05/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities and reason for the admission. The recommendations were "Pt. [patient] here for aggression towards RTC [residential treatment center] staff and AH/VH [auditory and visual hallucinations]. Recommend IT [individual therapy], GT [group therapy], RT [recreation therapy], along with med management."

2. Patient R2 was admitted on 06/28/14. The psychosocial assessment, done on 06/28/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities and reason for the admission. The recommendations were "Pt. [patient] admitted because he called 911 while having SI [suicidal ideation] with plan to cut self with knife. Pt. [patient] to benefit from safe and supportive environment, GT [group therapy], and coping skills."

3. Patient R3 was admitted on 06/30/14. The psychosocial assessment, done on 07/01/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities and reason for the admission. The recommendations were "Pt. [patient] is 16 male presenting with aggression. Pt. [patient] is assaultive toward male and female. Pt. [patient] is a cutter. History of inpatient hospitalization for similar issues. Police involvement. Pt. [patient] will stabilize with MM [medication management], pt. [patient] will attend GT [group therapy]/RT [recreation therapy] daily, IT/FT [individual therapy/family therapy] weekly."

4. Patient R4 was admitted on 06/30/14. The psychosocial assessment, done on 07/01/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities and reason for the admission. The recommendations were "Pt. [patient] is a 14 year old female who presents with suicidal ideation and told boyfriend in text message. Pt. [patient] to D/C [discharge] when stabilize per MD to F/U [follow up] with outpatient."

5. Patient L5 was admitted on 06/25/14. The psychosocial assessment, done on 06/28/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were only the reason for the admission. The recommendations were "Pt. [patient] presented due to psychotic symptoms believing there is poisonous gas and husband is trying to murder her."

6. Patient L6 was admitted on 07/07/14. The psychosocial assessment, done on 07/08/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities and reason for the admission. The recommendations were "Pt. [patient] is a 22 year old male admitted to KPH for suicidal ideation, depression, irritability and mood swings. Pt. [patient] to benefit from IT [individual therapy], process groups, psychiatric treatment, medication compliance and increase insight into coping skills."

7. Patient L7 was admitted on 07/05/14. The psychosocial assessment, done on 07/07/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were only the reason for the admission. The recommendations were "Pt. [patient] is a 27 year old with history of mental illness. She was not taking medication as prescribed leading to increase symptom including suicidal ideation with plans."

8. Patient L8 was admitted on 07/04/14. The psychosocial assessment, done on 07/06/14, did not include patient's strengths and individualized social services specific recommendations. The recommendations documented were generic in nature describing routine unit activities and reason for the admission. The recommendations were "Problems identified were opioid dependence. Pt. [patient] may be in need of structured treatment on the next level of care."


B. Staff Interviews

1. During an interview on 07/09/14 at 03:10 PM, the therapist 2 stated, "I get your point. The social assessments do not include individualized recommendations."


2. During an interview on 07/10/14 at 10:35 AM, the Director of Social Work stated, "I agree the social assessments do not include strengths and individualized recommendations."

3. During an interview on 07/10/14 at 8:40 AM, the Medical Director and the CEO both agreed that the social assessments do not include patient's strengths and individualized recommendations. The CEO stated, "We include patient's strengths in the treatment plans. We will start working on the changes."

Based on record review and staff interview, it was determined that the facility failed to perform and document an estimate of memory functioning with supportive information in the psychiatric evaluation for four (4) of eight (8) active sample patients (R3, R4, L5, and L8) and failed to perform and document an examination of orientation with supportive information in the psychiatric evaluation for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, L7, and L8) and an estimate of intellectual functioning with supportive information in the psychiatric evaluation for six (6) of eight (8) active sample patients (R1, R4, L5, L6, L7, and L8). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

Record Review:

1. Patient R1 was admitted on 07/04/14. The psychiatric evaluation, done on 07/05/14 stated, "Orientation X 3, estimate of intelligence normal". There was no supportive information documented.

2. Patient R2 was admitted on 06/28/14. The psychiatric evaluation, done on 06/28/14 stated, "Orientation A & O [alert and oriented]. There was no supportive information documented".

3. Patient R3 was admitted on 06/30/14. The psychiatric evaluation, done on 07/01/14, stated, "Memory recent and remote fair, orientation X 3". There was no supportive information documented.

4. Patient R4 was admitted on 06/30/14. The psychiatric evaluation, done on 07/01/14, stated, " Memory remote fair, recent fair, orientation X 3, estimate of intelligence normal " . There was no supportive information documented.

5. Patient L5 was admitted on 06/25/14. The psychiatric evaluation, done on 06/26/14 stated, "Memory long term intact, orientation X 3, estimate of intelligence average".There was no supportive information documented.

6. Patient L6 was admitted on 07/07/14. The psychiatric evaluation, done on 07/07/14, stated, "Orientation X 3, estimate of intelligence average". There was no supportive information documented.

7. Patient L7 was admitted on 07/05/14. The psychiatric evaluation, done on 07/06/14, stated, "Orientation X 3, estimate of intelligence average". There was no supportive information documented.

8.Patient L8 was admitted on 07/04/14. The psychiatric evaluation, done on 07/05/14, stated, "Orientation X 3, estimate of intelligence average, memory long term intact, short term 3/3 [3 out of 3]". There was no supportive information documented.

Interview:

During an interview on 07/10/14 at 11:00 AM, the Medical Director stated, "Cognitive testing has been an issue with us. I am aware of the problem. We have created a committee to address the issue and we are looking into it. Definitely it needs to be improved. I agree with you 100%".

Based on record review and interview, the facility failed to ensure that the treatment plans for six (6) of eight (8) active sample patients (R1, R2, R3, R4, L5, and L7) identified active treatment measures that addressed the individual patient's specific problems and treatment. Instead, the treatment plans either listed routine and generic discipline functions written as treatment interventions or listed general groups/activities to be provided for the patients as the interventions. The listed groups/activities, by title only, failed to include the specific focus or duration of treatment. In addition, some of the treatment plans failed to include interventions by key staff such as a physician. These deficiencies result in treatment plan that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment.

Findings include

A. Record Reviews

1. Patient R1, in treatment plan dated 7/5/14 for the problem of: "patient with increased aggression towards others and AH (audio hallucinations)/VH (visual hallucinations) of demons telling him to kill people and his family."

The treatment modality by the psychiatrist listed "Abilify and Teg" as an intervention; the frequency "daily" and "responsible staff name" was an illegible signature. The patient's MAR clarified the order to be Abilify 5 mg at bedtime; Tegretol chewable 100 mg twice daily and Clonidine 0.1 mg tab. every morning.

The treatment modalities (interventions) from nursing listed generic intervention stated "attend daily nursing education groups" and "provide feedback a minimum of one time a day in groups." Clinical services listed "participate in process groups daily" and "provide feedback a minimum of one time a day in groups." The treatment plan did not specifically address the patient's issues of aggression, and hallucinations (other than for the medication prescribed) to guide the staff in treatment. The treatment plan listed routine and generic discipline functions written as treatment interventions or listed general groups/activities to be provided for the patient as the interventions.


2. Patient R2, in treatment plan dated 6/28/14 for the problem of: "Danger to Self: patient having increased SI (suicidal intent) with plan to cut wrist with knife."

The role of psychiatrist and psychiatric interventions were not documented on the treatment plan. Treatment interventions from nursing did not address the patient's problem of suicidal intent. Nursing listed generic interventions such as; "attend daily nursing education groups" and "take a minimum of three showers within one week period." Clinical services stated; "participate in one process groups daily" and "participate in 5-6 recreational therapy groups per week (recreational therapy)." The treatment plan listed routine and generic discipline functions written as treatment interventions or listed general groups/activities to be provided for the patients as the interventions.


3. Patient R3, in treatment plan dated 6/30/14 for the problem of: " Danger to Others: patient is assaultive towards (M) mother & (F) father. History of cutting. History of hospitalizations doing similar behavior, Patient also threatens SI (suicide), history of police involvement."

The role of psychiatrist and psychiatric interventions were not documented on the treatment plan. Treatment interventions from nursing did not address the patient's problems of suicidal ideation, and potential for assaultiveness. Nursing listed generic interventions such as; "attend daily nursing education groups" and "take a minimum of three showers within one week period." Clinical services stated; "participate in one process groups daily" and "participate in 5-6 recreational therapy groups per week (recreational therapy)." There was no intervention listed on the treatment plan to safely manage suicidal threats and/or assaultive behavior from the patient. The treatment plan listed routine and generic discipline functions written as treatment interventions or listed general groups/activities to be provided for the patients as the interventions.

4. Patient R4, in treatment plan dated 7/3/14 for the problem of: "Danger to Self; patient is a 14 year old who presents with increase suicidal ideation."

The treatment modality by the psychiatrist listed "Abilify Lexapro, Trileptal" as an intervention; the frequency "daily" and "responsible staff name" was an illegible signature. Nursing listed generic interventions such as; "attend daily nursing education groups" and "take a minimum of three showers within one week period." Clinical services stated; "participate in one process groups daily" and "participate in 5-6 recreational therapy groups per week (recreational therapy)." These were interventions documented that addressed the patient's primary problem of suicidal ideation. There was no evidence that an alternative treatment plan appropriate for the patient's level of acuity had been developed.

5. Patient L5, in treatment plan dated 6/28/14 for the problem of: "Psychosis; patient presented due to belief she smells poisonous gas and H (husband) is trying to murder her."

Other than the generic nursing and clinical service interventions nursing and clinical service therapy did not address the patient's problem of psychosis. Also noted on 15 minute patient rounds, the patient was frequently listed "in room" "in bed."

On interview with patient 7/9/14, at approximately 11:00 AM, she said she would; "get up, wash up and go to group this afternoon." Patient demonstrated that she could accomplish her goal.

6. Patient L7 in treatment plan dated 7/7/14 for the problem of: "Danger to Self; suicide intent with a plan to set self on fire; feeling anxiety and overwhelmed; V/H (visual hallucinations) - shadows." Clinical services intervention provides "feedback a minimum of one time a day in groups" and nursing offers "daily nursing education groups." The other interventions were equally generic and did not address the patients problem(s).

Interview

1. During an interview on 7/10/14 at approximately 3:15 PM with RN1, the surveyor asked if RN1 could read the initialed "Responsible staff" on the physician entry on the treatment plans for R2 and R3. The response was; "I'm not sure who the doctor is. The initials look similar, but I can't tell."

2. During an interview on 7/10/14 at approximately 3:25 PM the Director of Nursing (DON) stated, "We've tried to make the treatment plans specific, but they're not very good."

3. During an interview on 07/10/14 at 11:00 AM, the Medical Director and the CEO agreed that the treatment plans could be improved and that it should include all types of interventions provided to the patients. They both also agreed that the treatment plan should be updated when there is a change in patient condition requiring restrictive interventions.

Based on record review, interview and policy review, the facility failed to identify the psychiatric intervention provided for four (4) of eight (8) (R2, R3, L7, and L8) active sample patients. One active sample patient (L5) did not have a Psychiatrist signature on the treatment plan and on a treatment plan update of 7/3/14. This failure results in the patient and other staff being unaware of which psychiatrist is assuming responsibility for treatment of the patient, the intervention being implemented and documenting progress toward treatment goals.

Findings include

Record Review

1. Review of the following treatment plans (dates in parentheses) revealed that the facility did not delineate the names and responsibilities, i.e. intervention of the psychiatrist for the following active sample patients. Patient R2 (6/28/14), Patient R3 (6/30/14), L7 (7/7/14), and L8 (7/6/14).

2. Patient's (L5) (6/28/14) treatment plan was not signed by a psychiatrist, and the treatment plan update, 7/3/14 was not signed by the psychiatrist.

Policy Review

Kingwood Pines Hospital, policy # T-114 reviewed 3/20/13 states on page 2 sections 13: "The team signatures section shall be signed by all treatment team members who participated in the care of the patient."

Interview:

1. During an interview on 7/10/14 at approximately 2:30 PM, the RN1 stated; "we do list the names of the team. I hadn't noticed that the doctor hadn't completed his intervention. I expect the treatment team should have noticed that and ask him/her to fill in their section."

2. During an interview on 07/10/14 at 11:00 AM, the Medical Director and the CEO agreed that the treatment plans could be improved and that it should include all types of interventions provided to the patients. They both also agreed that the treatment plan should be updated when there is a change in patient condition requiring restrictive interventions.

3. During an interview on 07/08/14 at 11:30 AM, physician 3 stated, "I see there are no interventions by the physician included in the treatment plans. I agree with you it should be there."

Based on observation, record review and interview, the facility failed to ensure active treatment was implemented and documented for patients based on individual patient needs/presenting behaviors.

Specifically the facility failed to:

A. Based on record review and interviews, the facility failed to monitor a discharge of minor female patient (Patient R4) in a safe manner resulting in an immediate jeopardy.

Patient R4 was admitted on 6/30/2014 to the adolescent acute psychiatric unit with the diagnosis of mood disorder, mixed. On 7/1/2014 s/he was placed on suicidal precautions (SP), assaultive precautions (AP), and on one (1) to one (1) observation while in room & bathroom.

The precautions of SP, AP and 1:1 precautions were continued daily on this patient; and the patient was discharged on 7/10/14 still being on these precautions. The attending Psychiatrist requested a telephone call from nursing for 7:00 AM on 7/10/14 to assess the decision to discharge the patient or not. There was no documented call made by the nurse to the physician. The patient was discharged without a physician's order and there was no nursing documentation of the patient's discharge.

Patient R4 was discharged on 7/10/14 without a physician's order resulting in an immediate safety concern, lack of accountability by the facility to monitor the discharge of a minor patient who was still on suicide, assault and one to one precautions. This failure to discharge a patient from a locked acute care psychiatric hospital without a written physician's order and discharge instructions poses immediate risk to the safety and well-being of the patient and potentially other patients in the facility resulted in an immediate jeopardy condition.

Interview:

1. On interview of RN2 (day shift nurse) at approximately 9:30 AM on 7/11/14 revealed that RN2 did not telephone the Psychiatrist at 7:00 AM. A telephone interview was conducted to the night nurse RN3 at 9:34 AM. RN3 reported no phone call was made as her shift ended at 7:00 AM and she left the facility without calling the psychiatrist. Both nursing staff was aware that the psychiatrist was contemplating discharge for the patient; however the phone call was never made to the psychiatrist.

2. On interview in the Conference room with physician 3, on 7/11/14 at approximately 9:10 AM, physician 3 reported that the phone call was not made to him/her and a discharge order had not been written by him/her.

3. During an interview on 07/11/14 at 10:00 AM, the medical director stated, "yes, the patient was discharged without a physician's order, which is not our policy".


The management team of the facility (CEO, Medical Director and Director of Nursing) was notified of an immediate jeopardy (IJ) condition at 10:15AM on 7/11/2014. The facility developed a plan of correction (POC) to address the IJ which was reviewed and found to be acceptable by the Federal and State Surveyors and the IJ was lifted.

B. Ensure proper monitoring for one active sample patient (R4) who was on 1:1 supervision for potential assaultive behavior and suicidal behavior. There was failure to document an elopement episode on 7/5/14 by patient R4 on the treatment plan alerting the treatment team of the incident.

Findings:

Record Review:

Patient R4 - became agitated and threatening at 7/5/14 at 5:44 PM and tried to elope from the facility. The Psychiatrist was called and ordered Zyprexa 10 mg p o for the patient's severe agitation. Two nurses were on either side of the patient holding her arms (restraint), walking her to her room. The patient took the medication without incident. The total time was 8 minutes of restraint. The documentation is clear and the follow-up was per S/R procedure. However, this incident was not addressed by the treatment team and the treatment plan was not updated.

C. Provide alternative programming/activities for patients who are too acutely ill or refuse to attend scheduled programming activities. This deficiency resulted in patients idly lying/sitting around the dayroom and not receiving active treatment.

Findings:

A.Observation:

1. On Unit 100 (PICU) surveyor noted three patients in the day room at 2:15 PM on 7/8/14 not attending group therapy. Non-sample patient C1, admitted on 6/30/14 was on the sofa, dozing off; C2 admitted on 7/5/14 was sitting in a lounge-type chair with his/her eyes closed and C3 admitted on 7/1/14 appeared to be resting with his/ her head on a table.

Review of the patient's group therapy attendance indicated the following:
C1 had not attended group since admission 6/30/14
C2 had attended a Process Group 7/5/14 for a brief 5 minutes on 7/8/14.
C3 had not attended a group since admission 7/1/14.

2. Patient R4 was observed sleeping in bedroom during goals and orientation group on 07/09/14 at 9:20 AM and during process group on 07/10/14 at 9:30 AM. The review of the group notes indicated that this patient's group activities attendance was sporadic. The treatment plan was not updated to reflect patient's behaviors and no alternative treatment modalities were implemented.

Interview:

1. During an interview on 07/09/14, the staff nurse 2 stated, "she chose not to go to group, we let her sleep, we cannot make her to go to group. She becomes impulsive if she goes to group".

2. During an interview on 07/10/14 at 9:45 AM, the MHT2 stated, "she does not want to go. All we do is to say it is group time. If she chooses not to go we cannot make her go".

Based on record review, three (3) of five (5) discharge summary (D1, D2, and D5) did not contain a recapitulation of the patient's hospitalization. This compromised the effective transfer of the patient's care to the next provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings:

Record Review:

1. Patient D1, admitted on 5/22/14 and discharged on 5/30/14, did not include "course of treatment."

2. Patient D2, admitted on 5/21/14 and discharged on 5/30/14, did not include "reason for admission and course of treatment."

3. Patient D5, admitted 5/27/14 discharged on 6/5/14 did not include "reason for admission and course of treatment."

Interview:

During an interview on 07/10/14 at 11:00 AM, the Medical Director stated, "I agree with you. The reason for admission and course of treatment are not demented. I will work with my medical staff."

Based on record review five (5) of five (5) discharge summary (D1, D2, D3, D4, and D5) did not include a brief summary of the patient condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk are not available to the aftercare providers.
Findings:
Record Review:
A review of discharge medical records for patients (D1, D2, D3, D4, and D5), the discharge summary of all five (5) sample patients did not include a brief summary of patient condition on discharge.
Interview:
During an interview on 07/10/14 at 11:00 AM, the Medical Director stated, "I agree with you, prognosis must be included and it is not there."

Based on interview and medical record review the facility failed to assure that the Medical Director, the Director of Nursing and the Director of Social Work monitored treatment and took corrective actions. Specifically,

1. Medical Director failed to provide adequate medical oversight to ensure quality medical services. (Refer to B144)

II. Director of Nursing failed to:

1. Adequately monitor the discharge of one active sample patient (R4) who continued to be on 1:1 observation, suicidal precautions, and assaultive precautions. The patient was discharged without a physician's written order. (Refer to B148)

2. Develop and document comprehensive treatment plans that included appropriate nursing interventions to guide nursing staff in the provision of nursing care for patients based on identified problems and behaviors for seven (7) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, and L7) . Nursing interventions were listed with non-specific or inappropriate parameters for patient monitoring and interventions based on identified patient needs. In addition, nursing interventions were not revised based on changes in the patient's status or response to treatment. (Refer to B148)

III. Director of Social Services failed to monitor and evaluate the quality and appropriateness of social services provided to patients at the facility. Specifically the Director of Social Services failed to assure that the social service assessments included individual patient's strengths and individualized recommendations for social work services from the data gathered for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, L7, and L8). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams. (Refer to B152)

Based on record review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. Specifically the Medical Director failed to assure that:

I. Social service assessments included individual patient's strengths and individualized recommendations for social work services from the data gathered for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, L7, and L8)). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams. (Refer to B108)


II. Physicians performed and documented an estimate of memory functioning with supportive information in the psychiatric evaluation for four (4) of eight (8) active sample patients (R3, R4, L5 and L8) and failed to perform and document an examination of orientation with supportive information in the psychiatric evaluation for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, L7, and L8) and an estimate of intellectual functioning with supportive information in the psychiatric evaluation for six (6) of eight (8) active sample patients (R1, R4, L5, L6, L7, and L8). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions. (Refer to B116)

III. That the treatment plans for six (6) of eight (8) active sample patients (R1, R2, R3, R4, L5, and L7) identified active treatment measures that addressed the individual patient's specific problems and treatment. Instead, the treatment plans either listed routine and generic discipline functions inappropriately written as treatment interventions or listed general groups/activities to be provided for the patients as the interventions. The listed groups/activities, by title only, failed to include the specific focus or duration of treatment. In addition, some of the treatment plans failed to include interventions by key staff such as a physician. These deficiencies result in treatment plan that fail to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific interventions needed and the purpose for each. This failure potentially results in inconsistent and/or ineffective treatment. (Refer to B122)

IV. Identify the psychiatric intervention provided for 4 of 8 (R2, R3, L7 and L8) active sample patients. One active sample patient (L5) did not have a Psychiatrist signature on the treatment plan and on a treatment plan update of 7/3/14. This failure results in the patient and other staff being unaware of which psychiatrist is assuming responsibility for treatment of the patient, the intervention being implemented and documenting progress toward treatment goals. (Refer to B123)

V. Provide and document active treatment measures including alternative interventions for patients based on individual patient needs/presenting behaviors. (Refer to B125)

VI. Discharge summaries for three (3) of five (5) discharge summary (D1, D2, and D5) contained a recapitulation of the patient's hospitalization. This compromised the effective transfer of the patient's care to the next provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133)

VII. Discharge summaries for five (5) of five (5) discharge summary (D1, D2, D3, D4, and D5) contained summary of the patient's condition on discharge. Therefore, critical clinical information indicating the patient's level of psychiatric symptomatology and risk was not available to the aftercare providers. (Refer to B135)

Based on observation, interview and record review, The Director of Nursing failed to:

1. Nursing failed to adequately monitor the discharge of one active sample patient (R4) who continued to be on 1:1 observation, suicidal precautions, and assaultive precautions. The patient was discharged without a physician's written order. (Refer to B125)

2. Develop and document comprehensive treatment plans that included appropriate nursing interventions to guide nursing staff in the provision of nursing care for patients based on identified problems and behaviors for siven (7) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, and L7) . The listed nursing interventions for patient monitoring were only discipline specific functions and the interventions were not based on identified patient needs. In addition, nursing interventions were not revised based on changes in the patient's status or response to treatment. (Refer to B122)

Interview:

During an interview on 7/10/14 at approximately 9:45 AM the DON stated; "the interventions are a check list. I didn't know about the doctors not writing their interventions. I don't know who is specifically responsible."

Based on record review and interviews, it was determined that the Director of Social Services failed to monitor and evaluate the quality and appropriateness of social services provided to patients at the facility. Specifically the Director of Social Services failed to assure that the social service assessments included individual patient's strengths and individualized recommendations for social work services from the data gathered for eight (8) of eight (8) active sample patients (R1, R2, R3, R4, L5, L6, L7, and L8)). As a result, the treatment team did not have current baseline social functioning on these patients for establishing treatment goals and interventions and social work specific recommendations regarding treatment of patient's psychosocial problems were not described for the treatment teams. (Refer to B108)

Interviews:


1. During an interview on 07/09/14 at 03:10 PM, the therapist 2 stated, "I get your point. The social assessments do not include individualized recommendations."

2. During an interview on 07/10/14 at 10:35 AM, the Director of Social Work stated, "I agree the social assessments do not include strengths and individualized recommendations."

3. During an interview on 07/10/14 at 8:40 AM, the Medical Director and the CEO both agreed that the social assessments do not include patient's strengths and individualized recommendations. The CEO stated, "We include patient's strengths in the treatment plans. We will start working on the changes."

Based on record review and interview, the facility failed to provide a MSW- prepared Director of Social Work, or to assign one of MSW- level staff currently employed at the facility to fulfill the duties, functions and responsibilities of the Director of Social Work. As a result, there was no professionally designed and directed social work program for eight (8) of eight (8) sample patients (R1, R2, R3, R4, L4, L5, L6, L7, and L8), as well as for the facility's entire patient population.

Record Review:

1. The review of the resume and the most recent job description of the Director of Clinical and Social Services dated 03/03/14 indicated that the Director of Social Work was not MSW qualified.

2. The director of quality improvement (QI) and risk management RM) who had the qualification of a licensed clinical social work was not involved in providing any oversight to the hospital social work department based upon record review and staff interviews. However, there was a job description for this staff member dated 01/01/14 which stated "Director of Social Services". The review of psychosocial assessments for patients R1, R3 and R4 indicated that these assessments were completed by the non-MSW prepared staff members and they were not reviewed and signed off by the MSW prepared staff.

Interviews:

1. During an interview on 07/09/14 at 10:10 AM, therapist one (1) stated, "I report to the director of clinical and social services. I do not get any supervision from MSW staff. We do have a couple of MSW on staff but they do not supervise me." Therapist 1agreed that the psychosocial assessment completed by him was not reviewed and signed off by MSW for eight (8) days after the completion.

2. During an interview on 07/09/14 at 03:10 PM, therapist two (2) stated, "not really" in response to when asked if he received any supervision from MSW prepared staff. Therapist two (2) further stated, "I provide therapy and social services and I report to the director of clinical and social services. It is my understanding that the director of QI and RM reviews and signs off on psychosocial assessment and if any issues identified, feedback is given." When asked if he has been given any feedback and any supervisory sessions were held over the last 3 to 4 months by the director of QI and RM, he stated, "No."

3. During an interview on 07/09/14 at 10:45 AM, the director of clinical and social services stated, "I have some LCSW on staff but they do not have any supervisory responsibilities. Director of QI and RM reviews and signs off on all psychosocial assessments."