HospitalInspections.org

Based on staff and patient interviews, observation, policies and procedures and review of the medical record for patient #1, it was determined that the hospital failed to update the patient's careplan when their was a change in her behavior as evidenced by:

Patient #1 was a 27 year old female who was admitted to hospital in November of 2012. The patient was moved two different units within the same building with her last transfer to Hitchman-A In February 2014. The patient had periods of irritability, impulsivity, and aggression toward peers and staff. During late 2014 the patient's mood and behavior had improved to the point that the patient was able to attend a day program starting October 2014 two days a week (Tuesday and Wednesday). It was documented that upon her return from the program she was very energetic. It was felt the patient's behavior was due to excessive caffeine consumption. The patient continued to go to the program throughout the month of October 2014, to refuse her medications and to exhibit aggressive behavior requiring seclusion. The patient agreed with treatment team to stop the day program, "patient stated it was not a good fit" and the treatment team because of the patient's unstable condition felt the patient's participation in the day program should be terminated. The patient had been frequently verbal and physically aggressive with sporadic refusal of medication.

The medical record review further revealed that the patient exhibited labile mood with aggression for two months leading into October 2014. The treatment team performed test to ensure the patient was not pregnant before placing the patient on Depakote. In January 2015, when the patient stated she thought she was pregnant attempts to get blood work for confirmation was difficult since patient refused testing. Finally on January 29, 2015 the patient agreed and allowed the testing for pregnancy which revealed a positive test. The patient was referred to UMMS high risk pregnancy program and has been compliant thus far with treatment and monitoring. She has been more cooperative and handling her liability actual walking away from situations which would previously led to aggression. The patient became pregnant sometime in December 2014 or January 2015. The treatment team has not certified the patient as lacking capacity to make her own decisions but has been discussing guardianship with family regarding decisions about the baby. Interview with patient #1 on 5/5/15 at 8:30am in the conference room on Hitchman-A the patient did not want to discuss how she got pregnant but clearly expressed her concern that she wanted to be discharged by the time the baby is born. She had no complaints about the care and complained of being tired only. The patient was alert and oriented x4 (person, place, time, and situation). Documents reviewed indicated that the patient has previously stated the sex was consensual and that she entered the male peer room. The hospital currently have staff that monitors the day-hall and performs checks on patients every 15 minutes.

There are also several notes in the patient's medical record from the period of November and December 2014 which stated that the patient was sexually aggressive toward male peers including following them around the unit. The behavior included provocative dancing on the day-hall.

The patient was exhibiting new sexually provocative behavior which was documented but nothing was documented regarding monitoring and managing the behavior on the patient ' s care plan. There was no documentation that the hospital addressed the patient's aggressive behavior and refusal of medications in a timely manner as part of the care planning process.