HospitalInspections.org

Based on review of facility policy and a review of hospital documentation, the hospital failed to implement a restraint policy with least restrictive interventions. The findings include:

Review of the restraint log dated 2/2017 to 8/2017 identified that restraint types included mitts, net, and 4 point restraints. Review of the physical restraint and seclusion of client policy identified in part, that the approved mechanical restraints approved for use at the hospital included use of leather cuffs for wrist and ankles which restrict movement of the patient to the bed. Four-point restraints are among the most restrictive of the restraint procedures. Prior to the initiation of restraint or seclusion, less restrictive interventions are used. The only acceptable reason for using restraint and seclusion without prior attempts at less restrictive measures is that the danger is so imminent and severe that any delay in using physical force to control a client would significantly increase the risk of harm to the client or others. The policy does not identify the use of 2 point restraints, a least restrictive restraint.

Based on review of the medical record, review of hospital documentation and interviews for five of six patients reviewed for restraint use (Patient #6, #15 #18, #19, #24), the hospital failed to ensure that the restraint records were completed accurately to reflect initiation of restraints, termination time, and/or patient debriefing. The findings include:



1a. Patient # 19's diagnoses included Borderline personality disorder and was admitted on 7/28/16. A physician order dated 5/25/17 directed 4 point restraints not to exceed 2 hours for self-injurious behavior. The Restraint and Seclusion Flow dated 5/25/17 identified that the patient was placed in 4 point restraints at 3:30 PM and released at 3:55 PM. The patient debriefing and treatment plan review was conducted at 3:50 PM while the patient was still in restraints, instead of after being released from restraints, therefore not in accordance with hospital policy.
b. A physician order dated 6/6/16 directed 4 point restraints not to exceed 2 hours for imminent danger to self. The Restraint and Seclusion Flow dated 6/6/17 identified that the patient was placed in 4 point restraints on 6/6/17 but lacked the time of initiation and termination of the restraints. The patient debriefing and treatment plan review also lacked the time that the debriefing was conducted.
c. A physician order dated 6/17/17 directed 4 point restraints not to exceed 2 hours for imminent danger to self. The Restraint and Seclusion Flow dated 6/17/17 identified that the restraints were applied at 2:30 PM and terminated at 3:15 PM. The patient debriefing and treatment plan review section was not completed to reflect that debriefing was conducted with the patient.

Interview with Nurse Manager #1 on 8/28/17 at 10:30 AM identified that staff was performing and documenting the debriefing before the patients' restraints were terminated in error and the flowsheets lacked complete documentation. Nurse Manager #1 further identified that the hospital has since changed their form and have re-educated staff on completion of the forms.



2. Patient #18's included bipolar disorder, borderline personality disorder and post traumatic disorder. A physician order dated 7/5/17 directed 4 point restraint up to 2 hours with net. The Restraint and Seclusion Flow dated 7/5/17 identified that the patient was placed in restraints at 10:30 PM and were discontinued on 7/6/17 at 12:00 AM. The patient debriefing and treatment plan review was completed at 11:00 PM while the patient was still in restraints and not in accordance with hospital policy. Although the flowsheet identified that the restraints were terminated at 12:00 AM, the Restraint and Seclusion Review Form identified that the patient's restraints were released at 11:50 PM. Interview with Nurse Manager #1 on 8/28/17 at 10:30 AM identified that the nurse documented the incorrect time on one of the forms.
The physical restraint and seclusion of a client policy directs in part, all use of restraints and seclusion is thoroughly documented in the client's medical record. The Posey Restraint Net may not be utilized with any other restraint device. When the restraint is discontinued, a debriefing is conducted with the client, the staff involved in initiating the intervention (if available) or the charge nurse and physician, and a family member (if applicable).



3a. Patient #6's diagnoses included schizoaffective disorder. Physician orders dated 8/3/17 directed four point restraints for assaultive behavior. The Restraint and Seclusion Flow dated 8/3/17 identified that the patient was placed in restraints at 7:00 AM and restraints were discontinued on 8/3/17 at 9:00 AM. The patient debriefing and treatment plan review was documented as completed at 7:00 AM while the patient was still in restraints and not in accordance with hospital policy.

b. Physician's orders dated 8/5/17 at 11:15 AM and 1:15 PM directed seclusion room for assaultive behavior for 2 hours. The Restraint and Seclusion Flow dated 8/5/17 identified that the patient was placed in restraints at 11:15 AM and restraints were discontinued on 8/3/17 at 3:00 PM. The patient debriefing and treatment plan review was documented as completed at 2:55 PM while the patient was still in seclusion and not in accordance with hospital policy.

Interview with the Director of Nursing 2 on 8/28/17 at 11:22 AM indicated that the nurse who completed the debriefing was unaware that it had to be completed after the restraints were removed.

The facility restraint policy dated 7/17 identified that when the restraint/seclusion is discontinued, a debriefing is conducted with the client with the purpose to understand the clients restraint experience.



4. Patient #15's was admitted to the hospital on 5/20/16 with diagnoses that included Post Traumatic Stress Disorder (PTSD) and Major Depressive disorder (MDD) and exhibited self injurious behaviors that included scratching his/her forearms and legs until they bleed. A physician's order dated 8/13/17 directed to apply bilateral mitt restraints not to exceed two hours for severe injurious behavior. Review of the corresponding Restraint and Seclusion Flow Sheet documented by RN #4 identified the rational for the choice of intervention was that the patient was exhibiting signs of increased anxiety as evidenced by scratching at scabbed areas bilateral forearms causing bleeding. Less restrictive interventions that were tried, but were ineffective included Constant Visual Observation (CVO), staff-client talk, decreased stimulation, and additional medications. Behavioral criteria for ending the restraint episode included that the patient becomes calm, is able to follow directions, and denies the urge to harm self. The restraint was initiated at 11:55 AM and discontinued at 1:40 PM. The client briefing documentation described the restraint episode and staff response in detail but failed to identify the client's response to the restraint episode and/or response to staff discussion. Additionally, review of the every fifteen minute restraint monitoring form identified that at the time of initiation, Patient #15 exhibited behaviors that included trying to hurt self, agitated and struggling, lying down, and breathing without difficulty. By 1:00 PM the patient was lying down, talking to staff, and breathing without difficulty. Those behaviors continued at 1:15 PM and 1:30 PM, however, the restraint was not released until 1:40 PM. The hospital failed to ensure that the restraints were released as soon as possible. The facility restraint policy dated 7/17 identified that when the restraint/seclusion is discontinued, a debriefing is conducted with the client with the purpose to understand the clients restraint experience.



5. Patient #24's was admitted to the hospital on 10/19/16. Diagnoses included schizoaffective disorder. A Physician order dated 8/7/17 at 7:07 PM directed to apply four point restraints for extreme agitation times two hours. Review of the corresponding Restraint and Seclusion Flow Sheet documented by RN #4 identified the rational for the choice of intervention was that the patient was exhibiting signs of severe agitation as evidenced by scratching his/her right arm with a plastic cup, attempting to harm self with a pen, and taking the phone off the cradle and wrapping the cord around his/her neck. Less restrictive interventions that were tried, but were ineffective included Constant Visual Observation (CVO), staff-client talk, and decreased stimulation. Behavioral criteria for ending the restraint episode included that the patient would become calm, able to follow simple directions, and denied the urge to harm self. The restraint was initiated at 7:07 PM and discontinued at 9:00 PM. The client debriefing documentation described the restraint episode and staff response in detail but failed to identify the client's response to the restraint episode and/or response to staff discussion, and breathing without difficulty. The facility restraint policy dated 7/17 identified that when the restraint/seclusion is discontinued, a debriefing is conducted with the client with the purpose to understand the clients restraint experience.

Based on medical record review, review of hospital documentation, and interview for one of two patients reviewed for consultative services (Patient #18), the hospital failed to ensure that the patient was evaluated timely for a hemorrhoid condition. The findings include:


a. Patient #18's diagnoses included bipolar disorder, borderline personality disorder and post traumatic disorder and was admitted on 6/23/17. The medical history and physical examination dated 6/23/17 identified that the patient had hemorrhoids. A physician order dated 8/2/17 directed a surgical consult for hemorrhoids. Review of the progress notes from admission to 8/28/17 failed to identify any documentation of the patient's hemorrhoids. Review of the medical record and interview with Nurse Manager #1 on 8/28/17 at approximately 1:10 PM identified that the patient was still waiting to get an appointment with a surgeon and sometimes it takes up to 3 months to get an appointment.

Based on review of the medical record and interview, for one of two patients reviewed for respiratory treatment needs (Patient #19, the hospital failed to ensure that nursing staff conducted respiratory assessments pre and post inhaler use. The findings include:


a. Patient #19's diagnoses included Borderline personality disorder and was admitted on 7/28/16. The as needed Medication Administration Records (MAR) dated June, July and August 2017 identified that the patient's orders included in part, Albuterol 90 mcg/inh aerosol, 2 puffs every 6 hours as needed for wheezing. The MAR identified that the patient used the inhaler on 6/30/17 at 11:05 AM, 7/8/16 at 8:30 PM, 7/13/17 at 5:50 PM, 8/3/17 at 4:30 PM, and 8/4/17 at 6:00 PM. Review of the progress notes for the preceding dates failed to identify lung assessments prior to the Albuterol treatment and after the treatment to assess its effectiveness.

Based on review of the medical record and interview of one of four patients reviewed for medical treatment planning (Patient #18), the hospital failed to ensure that the recovery plan was comprehensive to address the patient's medical issues. The findings include:


Patient #18's diagnoses included bipolar disorder, borderline personality disorder and post traumatic disorder and was admitted on 6/23/17. The medical history and physical examination dated 6/23/17 identified that the patient had hemorrhoids. Review of the progress notes from admission to 8/28/17 failed to identify any documentation of the patient's hemorrhoids. A physician order dated 8/2/17 directed a surgical consult for hemorrhoids. Review of the medical record and interview with Nurse Manager #1 on 8/28/17 identified that the patient was still waiting to get an appointment with a surgeon and sometimes it takes up to 3 months to get an appointment. A review of the recovery plans from admission through 8/14/17 failed to identify the issue of hemorrhoids with goals, objectives and a plan. Review of the medical record and interview with Nurse Manager #1 on 8/28/17 at 1:00 PM identified that the recovery plan lacked a problem and interventions for the patient's hemorrhoids and could not explain why this problem was not addressed in the recovery plan.

The facility policy for treatment/recovery planning identified that the Recovery Team will review/modify the plan at the Collaborative Team Meeting

Based on a tour of the pharmacy department, review of facility policies, review of controlled substance documentation and observations, the facility failed to ensure that one vial of methadone tablets was properly labeled during storage. The findings include:


A tour of the pharmacy department was conducted on 8/29/17 at 8:30 AM with the Director of Pharmacy. Observation of the class 2 Controlled Drug Storage safe (C2 safe) identified a small, brown, plastic bottle with a pharmacy label affixed. The label included "50 mg" handwritten in large black numbers and letters consistent with a magic marker. The pharmacy label was obscured by the magic marker, however, the name of Patient #22 was visible. The prescription number, lot number and expiration date were obscured. Inspection of the contents of the bottle identified several 1/4 tablets and several 1/2 tablets.

Interview with Director of Pharmacy on 8/29/27 at 9:05 AM identified that he/she was using Patient #22's Methadone prescription bottle to store divided doses of Methadone tablets to be utilized if/when another patient required a dosage other than a full tablet of Methadone. The Methadone bottle lacked clear documentation of a pharmaceutical lot number and expiration date.

Review of Patient #22's clinical record identified that he/she had been admitted to the hospital on 3/30/17, was on a methadone maintenance program during hospitalization, and was discharged on 6/21/17.

Based on observation and interview during a tour of the kitchen, the hospital failed to ensure that the kitchen equipment was maintained for cleanliness and/or that the dishwasher temperatures were within acceptable ranges. The finding includes:

a. During a tour of the kitchen on 8/28/17 at 11:00 AM, observation identified the fryolator and stove/oven were heavily coated with grease and old food. Interview with the Supervisor/Chef at that time identified that the cooking equipment is cleaned two times per month and the facility does not maintain documentation to reflect when it was cleaned or adherence to the cleaning schedule.

b. Review of the dishwashing temperature logs from January to August 2017 identified wash temperatures from 127 degrees to 165 degrees (acceptable range 140-160 degrees). Review of the temperature logs and interview with the Supervisor/Chef at that time identified that the wash temperatures should be 140-160 degrees. Additionally, the logs identified that for any deviation below 5 degrees in the optimum temp range, notify Plant Ops, above 5 degrees notify the Supervisor/Chef and to record the date and initial daily. Further interview with the Supervisor/Chef failed to identify that anyone was notified when the wash temperatures were not acceptable. In additional, the temperature logs dated January to August 2017 lacked intermittent documentation of wash and rinse temperatures to reflect that temperatures were monitored.

Based on medical record review and staff interview it was determined that the Psychosocial Assessments for six (6) of eight (8) patients (Patients A2, A3, B1, B3, C1 and C2) failed to include a description of the anticipated role of the social service staff in discharge planning. This failure results in no information being available to the other members of the multidisciplinary treatment team of the efforts to be made by social service staff.

The findings include:

I. Medical Record Review:

1. Patient A2: The Psychosocial Assessment dated 6/25/17 had no description of the anticipated role of the social service staff toward discharge planning.

2. Patient A3: The Psychosocial Assessment dated 6/25/17 had no description of the anticipated role of the social service staff toward discharge planning

3. Patient B1: The Psychosocial Assessment dated 7/22/15 had no description of the anticipated role of the social service staff toward discharge planning.

4. Patient B3: The Psychosocial Assessment dated 5/19/17 had no description of the anticipated role of the social service staff toward discharge planning.

5. Patient C1: The Psychosocial Assessment dated 8/8/17 had no description of the anticipated role of the social service staff toward discharge planning.

6. Patient C2: The Psychosocial Assessment dated 8/7/17 had no description of the anticipated role of the social service staff toward discharge planning.

II. Staff Interview:

On 9/26/17 at 1:00 p.m. the Director of Social Work was interviewed. A partial focus for the interview was the findings described in Section I, above. After examining the six (6) Psychosocial Assessments the Director agreed that there was not present a description of what efforts the social service staff would anticipate as necessary for discharge planning.

Based on medical record review and staff interview it was determined that for five (5) of eight (8) patients (Patients A1, A2, B1, B3 and C1) the Psychiatric Evaluations failed to contain a description of patient assets in descriptive, not interpretive fashion. This failure results in the inability to select treatment modalities that might include patient achievements, interests, hobbies, etc by the other members of the multidisciplinary treatment team.

The findings include:

I. Medical Record Review:

1. Patient A1: The Psychiatric Evaluation dated 5/30/17 stated as the patient's assets "Educational [illegible writing] is his strength. Patient has no support in the community."

2. Patient A2: The Psychiatric Evaluation dated 6/2/17 stated "Some education. Poor

3. Patient B1: The Psychiatric Evaluation dated 7/16/15 stated "Going to school".

4. Patient B3: The Psychiatric Evaluation dated 5/16/17 stated "Love & caring for people."

5. Patient C1: The Psychiatric Evaluation dated 7/28/17 stated "Religion & faith."

II. Staff Interview:

On 9/26/17 at 1:30 p.m. the clinical director was interviewed. A part of the interview was a focus on the issue of assessment of assets as described in Section I, above. The clinical director agreed that the assessments were ill-defined. The clinical director stated that this finding had been identified by JACHO surveyors recently.

Based on record review and interview, the facility failed to formulate treatment goals that were relevant to the patients' psychiatric condition for eight (8) of eight (8) active sample patients (A1, A2, A3, B1, B2, B3, C1 and C2). The goals were either not measureable or were staff goals (what the staff wanted the patient to achieve) rather than an outline of mental status or functional level to be obtained. Without a set of defined goals against which to measure progress, it is difficult to judge effectiveness of treatment and implement possible change in treatment in the case of lack of progress.

Findings include:

A. Record Review

1. Facility policy, titled "Treatment & Recovery Planning in Patient Psychiatric Units", policy # 3.1.3, last revised 11/13, stated: "Short-term goals & [and] objectives should include expected attainment dates." There was no other definition of goals in the policy.

2. In Patient A1's MTP, dated 6/6/17, the staff goal for the problem of "[Name of patient] is a 47 year old [man/woman] with a long h/o [history] of psychiatric illness and substance abuse, who was transferred from [name of facility] on 8/30/17 on a probate status. [S/he] was admitted to [name of hospital] after starting a fire at [his/her] apartment where [s/he] was found naked. [S/he] presented in a delusional state. [S/he] was discharged from [name of psychiatric unit] on 4/18/17. After a 17 day admission, [s/he] was discharged from [name of facility] in-patient psychiatric unit on 10/26/16. As per record [s/he] has not been taking [his/her] psychotropic medications and admitted to be taking up to 2000 Benadryl pills a day which [s/he] abused in the past. On the unit [s/he] presented in a delusional, guarded disorganized state. [S/he] was placed on CVO for POO/POS/UB [Continuous Visual Observation for Protection Of Self/Unpredictable Behavior]."
The staff goal was: "[Name of patient] will identify the benefits of participating in the program on the unit and the recommended treatment."

3. In Patient A2's MTP, dated 6/8/17, the staff goal for the identified problem of "Patient is a 65y.o. [year old] [male/female] with H/O [History Of] Schizoaffective Disorder, who was probated to here from Bridgeport Hospital. Patient was brought in to Bridgeport Hospital by PD [Police Department] after patient's sister called 911 reported that patient was observed to be increasingly paranoid and delusional. When police arrived to [his/her] house, patient was holding the scissors and [s/he] was threatening to stab them. Patient was tazed 3 times by police and brought into Bridgeport Hospital ED [Emergency Department]. Patient was started on medications which [s/he] has been refusing and placed on involuntary protocol ordered by court. [S/he] received Prolixin Decanoate and torelating [sic] well," was: "Patient will take medications and participate in groups."

4. In Patient A3's MTP, dated 9/12/17, the staff goal for the problem: "Patient is a 44 y.o. single Portuguese speaking [male/female] who was transferred to PICU [Psychiatric Intensive Care Unit] on 6/24/17 from CVH [Connecticut Valley Hospital]. Patient was admitted to [name of hospital] on 8/6/15. [S/he] reportedly was doing well at the cottage where [s/he] was since May of 2015. However in August 2015 [s/he] was observed to be more paranoid and delusional. [S/he] put on fire small waste basket and [s/he] was trying to burn some old carts" was: "Patient will take [his/her] medications and will participate in unit activities."

5. In Patient B1's MTP, dated 5/20/17, the staff goals for the problem of: "Pt seen, [s/he] is a 33 y.o. Caucasian [male/female] [DOB 11/26/1983] who was admitted to GBCMHC [Greater Bridgeport Community Mental Health Center] on 07/18/2015 and transferred to PICU II on 08/16/2017. Over the past month overall there has been some improvements in [his/her] mood and has had fewer episodes of mitten restraints. [S/he] was admitted to Bridgeport Hospital from 08/15/2017 for constipation and was on admission there till 08/21/2017. Nursing reports that since [his/her] return [s/he] has been more visible and out of [his/her] room more. [S/he] still had some episodes of scratching but was re-directable and was not put in mitten restraints over the past weekend. We met with [him/her] in the comfort room. [S/he] reported [his/her] mood today as "depressed" and continued to endorse suicidal ideations but has no intent or plan at this time. [S/he] has been more visible on the unit today and [his/her] affect is less constricted and more reactive. [S/he] remains on ALO [Alternative Line Of Sight] for safety. [S/he] denied perceptual disturbance, was not internally preoccupied and there was no loss of reality testing. [S/he] is yet to do blood work [thyroid panel], once it is done we will start /him/her] on Lithium: 33 y/o [male/female] who looks younger than stated age, is disheveled but is appropriately dressed. Mood: "depressed". Affect is less constricted and more reactive. Thought process is concrete. Thought content vague suicidal ideations but no intent or plan at this time; [s/he] denies AH/VH/HI [Audio Hallucinations/Visual Hallucinations/Homicidal Hallucinations], has mild persecutory delusions. Insight and judgment are both limited. AAO x 3 Alert And Oriented times 3]." was: "Will participate in at least 1 group activity daily."

6. In Patient B2's MTP, dated 7/11/17, the staff goal for the problem of: "Paranoia and delusions, pt. baseline. Denies effects from meds. No acute behavior issues," was: "The patient will continue to comply with administration of all prescribed medications."

7. In Patient B3's MTP, dated 8/16/17, the staff goals for the problem of: "Pt is a 51 y/o Caucasian [male/female] [DOB 08/16/1965] who was transferred to PICU II today from CTU. [S/he] has a reported diagnosis of Schizoaffective Disorder and was admitted to CTU on 05/16/2017. As per [his/her] admission note [s/he] was transferred to GBCMHC from Danbury Hospital where [s/he] had been on admission since 02/16/2017. I met with [him/her] in [his/her] room to tell [him/her] that [his/her] care will be transitioning to [name of doctor] today as we have a new patient coming to the unit. [S/he] remains disorganized and bizarre and it was unclear if [s/he] fully understood what I was saying. [His/her] affect was labile and [s/he] cried on and off during the encounter without stating what was so distressing. Despite this [s/he] still denied any suicidal or homicidal ideations. [S/he] still has loose associations, echolalia, and changing associations. [S/he] reports compliance with [his/her] medications. We will continue the taper of [his/her] oral Risperdal and will reduce it to 2mg PO HS. [S/he] was evaluated for the need to have CVO [Continuous Visual Observation] to bathroom; [s/he] denies any suicidal or homicidal ideations, intent or plan and has not reported suicidal ideations since [his/her] admission to this unit. [S/he] will not require CVO to bathroom.51 y/o [male/female] who looks older than stated age, is disheveled, makes occasional eye contact but is not related and is poorly engaged in the encounter. [S/he] still has abrupt, bizarre movements that appear to be as a result of being internally preoccupied. Speech is less pressured but still has echolalia and clanging associations. Mood - not stated. Affect is labile. Thought process - disorganized, incoherent, with loose associations and multiple derailments. Thought content - [s/he] is responding to internal stimuli, has bizarre and persecutory delusions, and is religiously preoccupied." were: "Attend at least 2 groups [sic] activities on the unit a day" and "comply with medications 100% of the time."

8. In Patient C1's MTP, dated 8/14/17, the staff goals for the problem of: "69 years old divorced Caucasian [male/female], probated to GBCMHC on 4/25/17 and subsequently admitted to this facility on 7/28/17 due to psychiatric decompensation in the context on non-adherence with treatment. Patient has been isolative, spending most of [his/her] time in bed, disorganized, perseverative, paranoid, eating poorly and refusing to answer questions in the absence of [his/her] power of attorney. Patient believes that [his/her] conservator though is an imposter. Patient has been declining prescribed Zyprexa and Klonopin despite psychoeducation because [s/he] doesn't believe [s/he] has a mental illness. Patient denied depression, anxiety, suicidality and homicidally. Patient has remained guarded and paranoid and hasn't engaged in [his/her] treatment" were: "Patient will agree to daily assessment by nursing staff and psychiatrist for 1 week "Patient will agree to take medications daily as prescribed to address psychosis for 1 week," "patient will eat at least one meal a day an spent [sic] 1 hour a day in the community for 1 week," "patient will agree to daily assessment by nursing staff, psychiatrist for 1 week," and "patient will agree to take medications daily as prescribed to address psychosis for 1 week."

9. In Patient C2's MTP, dated 9/19/17, the difficult to measure goal for the problem of: "Patient has been intrusive during this review period and has had several arguments with a female peer. Patient has been argumentative with staff and has lost some privileges. [His/her] speech is less pressured and [his/her] thoughts have been more organized. Patient denied AH/VH/SI/HI. Patient exhibited some grandiosity at times. Patient has been less flirtatious on the unit. Patient has been adherent with medications and complained of ejaculatory problems. [His/her] Zyprexa was decreased to 25mg po q day to address this issue. Depakote level=58. Platelet count decreased to 113. Patient is no longer on droplet precautions. [S/he] has a level 3. Patient has participated to groups on the unit. Psychoeducation has been provided as patient has been able to identify 1 symptom of [his/her] mental illness and the beneficial effect of [his/her] medications," was: "Patient will learn more about [his/her] mental illness by participating to [sic] groups daily on the unit."


B. Interviews

1. In an interview on 9/26/17 at 9:38 a.m., the staff and difficult to measure goals on the MTPs were discussed with RN1. She did not dispute the findings.

2. In an interview on 9/26/17 around 11:00 a.m., the generic staff goals on the MTP was discussed with the Nursing Director. She agreed that the short-term goals were generic.

3. On 9/26/17 at 1:30 p.m. the Clinical Director was interviewed. A partial focus was the findings described in Section I, above. Short-term goals were not patient goals and/or behaviorally measureable. The director agreed with the findings and stated this issue had been identified by a recent JACHO (Joint Commission for Hospital Accreditation) survey, and was currently being addressed to improve the facility's treatment plans.

Based on record review and interview, the facility failed to develop Multidisciplinary Treatment Plans (MTPs) that evidenced sufficient individualized planning of psychiatrist and nursing interventions for eight (8) of eight (8) active sample patients (A1, A2, A3, B1, B2, B3, C1 and C2). The physician interventions were actually discipline tasks written as treatment intervention. Active sample patient A1 was the only one (1) who had a psychiatric nursing intervention. Failure to clearly describe specific interventions on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs.


Findings include:

A. Record Review

1. Facility policy, titled "Treatment & Recovery Planning - In-Patient Psychiatric Units," policy # 3.1.3, last revised 11/13, stated: "Treatment interventions should be assigned to specified disciplines, be spelled out in behavioral terms."

2. In Patient A1's MTP, dated 6/6/17, the generic interventions for the problem of "[Name of patient] is a 47 year old [man/woman] with a long h/o [history] of psychiatric illness and substance abuse, who was transferred from [name of facility] on 8/30/17 on a probate status. [S/he] was admitted to [name of hospital] after starting a fire at [his/her] apartment where [s/he] was found naked. [S/he] presented in a delusional state. [S/he] was discharged from [name of psychiatric unit] on 4/18/17. After a 17 day admission, [s/he] was discharged from [name of facility] in-patient psychiatric unit on 10/26/16. As per record [s/he] has not been taking [his/her] psychotropic medications and admitted to be taking up to 2000 Benadryl pills a day which [s/he] abused in the past. On the unit [s/he] presented in a delusional, guarded disorganized state. [S/he] was placed on CVO for POO/POS/UB [Continuous visual Observation for Protection of Others/Protection of Self/Unpredictable Behavior]"were: Physician: Evaluate response to treatment, monitor side effects, Psychoeducation, stressing adherence to treatment, need to abstain from substance use. Work with OP [Out Patient] team on a safe discharge."
Nursing intervention:"Nursing staff will; encourage client to participate in daily unit activities and groups."

3. In Patient A2's MTP, dated 6/8/17, the physician intervention for the identified problem of "Patient is a 65y.o. [male/female] with Schizoaffective Disorder, who was probated to here from Bridgeport Hospital. Patient was brought in to Bridgeport Hospital by PD after patient's sister called 911 reported that patient was observed to be increasingly paranoid and delusional. When police arrived to [his/her] house, patient was holding the scissors and [s/he] was threatening to stab them. Patient was tazed 3 times by police and brought into Bridgeport Hospital ED. Patient was started on medications which [s/he] has been refusing and placed on involuntary protocol ordered by court. [S/he] received Prolixin Deaconate and to relating well," was: "Patient will take medications and participate in groups.'

4. In Patient A3's MTP, dated 9/12/17, the physician intervention for the problem: "Patient is a 44 y.o. single Portuguese speaking [male/female] who was transferred to PICU on 6/24/17 from CVH [Connecticut Valley Hospital]. Patient was admitted to [name of hospital] on 8/6/15. [S/he] reportedly was doing well at the cottage where [s/he] was since May of 2015. However in August 2015 [s/he] was observed to be more paranoid and delusional. [S/he] put on fire small waste basket and [s/he] was trying to burn some old carts" was: "Patient will take [his/her] medications and will participate in unit activities."

5. In Patient B1's MTP, dated 5/20/17, the physician intervention for the problem of: "Pt seen, [s/he] is a 33 y.o. Caucasian [male/female] [DOB 11/26/1983] who was admitted to GBCMHC on 07/18/2015 and transferred to PICU II on 08/16/2017. Over the past month overall there has been some improvements in [his/her] mood and has had fewer episodes of mitten restraints. [S/he] was admitted to Bridgeport Hospital from 08/15/2017 for constipation and was on admission there till 08/21/2017. Nursing reports that since [his/her] return [s/he] has been more visible and out of [his/her] room more. [S/he] still had some episodes of scratching but was re-directable and was not put in mitten restraints over the past weekend. We met with [him/her] in the comfort room. [S/he] reported [his/her] mood today as "depressed" and continued to endorse suicidal ideations but has no intent or plan at this time. [S/he] has been more visible on the unit today and [his/her] affect is less constricted and more reactive. [S/he] remains on ALO [Alternative Line Of Sight] for safety. [S/he] denied perceptual disturbance, was not internally preoccupied and there was no loss of reality testing. [S/he] is yet to do blood work [thyroid panel], once it is done we will start /him/her] on Lithium. 33 y/o [male/female] who looks younger than stated age, is disheveled but is appropriately dressed. Mood: "depressed". Affect is less constricted and more reactive. Thought process is concrete. Thought content vague, suicidal ideations but no intent or plan at this time; [s/he] denies AH/VH/HI, has mild persecutory delusions. Insight and judgment are both limited. AAO x 3 [Alert And Oriented times 3]."was: "Will participate in at least 1 group activity daily."

6. In Patient B2's MTP, dated 7/11/17, for the problem of: "Paranoia and delusions pt baseline. Denies SE [side effects] from meds. No acute behavior issues."
The physician intervention was: "The patient will continue to comply with administration of all prescribed medications."

7. In Patient B3's MTP, dated 8/16/17, the generic physician intervention for the problem of: "Pt is a 51 y/o Caucasian [male/female] [DOB 08/16/1965] who was transferred to PICU II today from CTU. [S/he] has a reported diagnosis of Schizoaffective Disorder and was admitted to CTU on 05/16/2017. As per [his/her] admission note [s/he] was transferred to GBCMHC from Danbury Hospital where [s/he] had been on admission since 02/16/2017. I met with [him/her] in [his/her] room to tell [him/her] that [his/her] care will be transitioning to [name of physician] today as we have a new patient coming to the unit. [S/he] remains disorganized and bizarre and it was unclear if [s/he] fully understood what I was saying. [His/her] affect was labile and [s/he] cried on and off during the encounter without stating what was so distressing. Despite this [s/he] still denied any suicidal or homicidal ideations. [S/he] still has loose associations, echolalia, and changing associations. [S/he] reports compliance with [his/her] medications. We will continue the taper of [his/her] oral Risperdal and will reduce it to 2mg PO HS. [S/he] was evaluated for the need to have CVO to bathroom; [s/he] denies any suicidal or homicidal ideations, intent or plan and has not reported suicidal ideations since [his/her] admission to this unit. [S/he] will not require CVO to bathroom. MSE: 51 y/o [male/female] who looks older than stated age, is disheveled, makes occasional eye contact but is not related and is poorly engaged in the encounter. [S/he] still has abrupt, bizarre movements that appear to be as a result of being internally preoccupied. Speech is less pressured but still has echolalla [sic] and clanging associations. Mood - not stated. Affect is labile. Thought process - disorganized, incoherent, with loose associations and multiple derailments. Thought content - [s/he] is responding to internal stimuli, has bizarre and persecutory delusions, and is religiously preoccupied. I/J - Impaired."
The two physician interventions were: "Attend at least 2 groups [sic] activities on the unit a day" and "comply with medications 100% of the time."

8. In Patient C1's MTP, dated 8/14/17, the generic physician interventions for the problem of: "69 years old divorced caucasian [male/female], probated to GBCMHC on 4/25/17 and subsequently admitted to this facility on 7/28/17 due to psychiatric decompensation in the context on non-adherence with treatment. Patient has been isolative, spending most of [his/her] time in bed, disorganized, perseverative, paranoid, eating poorly and refusing to answer questions in the absence of [his/her] power of attorney. Patient believes that [his/her] conservator though is an imposter. Patient has been declining prescribed Zyprexa and Klonopin despite psychoeducation because [s/he] doesn't believe [s/he] has a mental illness. Patient denied depression, anxiety, suicidality and homicidality. Patient has remained guarded and paranoid and hasn't engaged in [his/her] treatment," were: "Patient will eat at least one meal a day and spent [sic] 1 hour a day in the community for 1 week." "Patient will agree to daily assessment by nursing staff and psychiatrist for 1 week," and "Patient will agree to take medications daily as prescribed to address psychosis for 1 week.

9. In Patient C2's MTP, dated 9/19/17, the generic physician intervention for the problem of: "Patient has been intrusive during this review period and has had several arguments with a female peer. Patient has been argumentative with staff and has lost some privileges. [His/her] speech is less pressured and [his/her] thoughts have been more organized. Patient denied AH/VH/SI/HI. Patient exhibited some grandiosity at times. Patient has been less flirtatious on the unit. Patient has been adherent with medications and complained of ejaculatory problems. [His/her] Zyprexa was decreased to 25mg po q day to address this issue. Depakote level=58. Patient presents with WBC=4.6. Platelet count decreased to 113. Patient is no longer on droplet precautions. [S/he] has a level 3. Patient has participated to groups on the unit. Psychoeducation has been provided as patient has been able to identify 1 symptom of [his/her] mental illness and the beneficial effect of [his/her] medication "was, "Patient will learn more about [his/her] mental illness by participating to [sic] groups daily on the unit."


B. Interviews

On 9/26/17 at 1:30 p.m. the Clinical Director was interviewed. A partial focus was the findings described in Section A, above: namely, that the interventions were generic discipline functions and were not patient specific. The director agreed with the findings and stated this issue had been identified by a recent JACHO survey, and was currently being addressed to improve the facility's treatment plans.

Based on record review and interview, the Nursing Director failed to ensure that Psychiatric Nursing Intervention were included in the Master Treatment Plans [MTPs] of eight (8) of eight (8) active sample patients (A1, A2, A3, B1, B2, B3, C1 and C2). This deficiency prevents the rest of the treatment team from knowing the specific role of the nursing staff in patients' treatment.

Findings /include:

A. Medical Record Review

None of the MTPs of the eight (8) active sample patients included nursing interventions related to the psychiatric needs of eight (8) of eight (8) active sample patients, dates of MTPs in parenthesis: (A1 (6/6/17), A2 (6/8/17), A3 (9/12/17), B1 (8/20/17), B2 (7/11/17), B3 (8/10/17), C1 (8/01/17) and C2 (9/19/17)).


B. Interview

In an interview on 9/26/17 around 11:00 a.m., the lack of psychiatric nursing interventions on the Master Treatment Plans was discussed with the Nursing Director. She did not dispute the findings.

Based on medical record review and staff interview it was determined that the Director of Social Work failed to--
Ensure that six (6) of eight (8) Psychosocial Assessments (Patients A2, A3, B1, B3, C1 and C2) contained a description of the anticipated role of the social service staff in discharge planning. This failure results in no information being available to the other members of the multidisciplinary treatment team about efforts that might be made toward discharge planning. (Refer to B108 for details).