HospitalInspections.org

Based on record review, medical record review, and staff interview, the facility failed to ensure the patient's and/or their representatives had the right to participate in the development and implementation of his or her plan of care for nine of nine patients reviewed for treatment plans (#2, #7, #11, #12, #13, #14, #15, #17, and #20).



Findings were:

Facility policy number CS-02 titled "Treatment Planning: Integrated/Multidisciplinary" stated in part, "Purpose: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.
Policy: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.
Procedure:
...3. The Social Worker, Recreation Therapist/Assistant& other treatment team members, as indicated by program level, is responsible for:
*Documenting additional treatment plan interventions as clinical assessments, patient observations and significant other information reveals further strengths, limitations or concerns. These interventions could include advocacy services to enhance the natural support system, facilitating environmental modifications or creating new support systems ....
6. Multi-Disciplinary Team Members or Designee is responsible for:
...*Documenting patient's coping limitations and strengths and devises interventions which utilize strengths as well as any discharge/continuing stay criteria.
*Documenting specific plan for family/significant other involvement in treatment and continuing care."

Review of the medical records for patients #2, #7, #11, #12, #13, #14, #15, #17, and #20 revealed no documentation of family notification of date, time, and location of each meeting so he or she could actively participate in the development and periodic review of the patients' individualized treatment plan.

Review of the medical record for patient #7 revealed Patient #7's multidisciplinary integrated treatment plan dated 11/11/21 had the following areas left blank: treatment plan summary by discipline - Nursing, physician services, utilization review and discharge planning. The area of LAR/primary support notification was left blank. The social services area stated in part, "documentation of family/significant other involvement" was left blank. The individualized patient treatment planning section which indicated the patient's understanding of treatment goals and patient's wishes to include other goals was left blank. Patient #7's treatment plan was incomplete and had no indication patient or family was involved.

Review of the medical record for patient #11 revealed they were admitted on 12/9/21, there was no information of family involvement on the original treatment plan. Patient #11 had several treatment plan reviews and update with physician certification. The Social Services documentation of family/significant other involvement stated the following:
On 12/16/21, "limited support"
On 12/21/21, "limited support"
On 12/28/21, "Pt [patient] has support through his nursing home and son"
On 1/4/22, "Sister is supportive"
Patient #11's treatment plan had no indication family was involved or were notified of the date, time, and location of each meeting so that he or she could participate.

Review of the medical record for patient #15 revealed they were admitted on 5/25/21 at 3:30 pm for delusional disorder and had a medical power of attorney [MPOA].
Patient #15's psychiatric evaluation dated 5/25/21 at 6:27 pm stated in part, " The patient has odd and delusional thinking. The patient is a poor historian .... He was not able to give reliable information ... The patient was disoriented to place, time, and situation. The patient reports a moderate anxiety level. The patient did not [sic] being asked questions. The patient has poor insight into his situation.
Diagnostic Impression - Admission assessment:
...Plan: ...4) Social worker to work on discharge planning. The patient will need nursing home placement ...
Anticipated Disposition: Nursing Home
Anticipated Follow-Up: PCP, Pharmacotherapy Management."

Patient #15's multidisciplinary integrated treatment plan had the following areas left blank: liabilities and special needs, patient strengths and assets, tentative discharge plan, and discharge criteria. This was signed by the nurse, physician and patient on 5/25/21 at 6:22 pm. The area of LAR/primary support notification was left blank.

Patient #15's treatment plan review and update with physician certification was signed by treatment team members and the patient at an unknown date and time. The "treatment plan summary by discipline - social services" stated in part, "changes status of all identified problems and each long/short term goal: [Patient #15] is starting to attend groups; Patients response & benefit from treatment interventions: benefits from meds & groups; Documentation of family/significant other involvement: (therapy, family participation, preferences, needs or d/c plan needs) family wants 24/7 home care." This update was signed by the physician on 6/1/21 at 2:22 pm.
Patient #15's treatment plan had no indication family was involved or were notified of the date, time, and location of each meeting so that he or she could participate.

A review of the clinical record for Patient #17 revealed he was a 79-year-old male admitted on 5/20/21 with admitting diagnosis of delusional disorder. He was placed on violence/homicide precautions and falls precautions upon admission.
The treatment plan of Patient #17 addressed aspects of his care. An update to the plan on 5/25/21 included the following nursing narrative note on his clinical presentation:
"Continues to be extremely confused, verbally & sexually inappropriate. Difficult to redirect & closely monitored for falls. He had no sleep x 24 hours. Refuses medication & blood sugar checks." The social services section of the update included a section entitled, "DOCUMENTATION OF FAMILY/SIGNIFICANT OTHER INVOLVEMENT: (THERAPY, FAMILY PARTICIPATION, PREFERENCES, NEEDS OR D/C PLAN NEEDS)." The narrative note entered in this section read only, "family is active in tx & dc planning."

In the same social services section on a treatment plan update of 6/1/21, the note read only, "family to decide on skilled nursing facility."

Patient #17's treatment plan had no indication family was involved or were notified of the date, time, and location of each meeting so that he or she could participate.

In an interview on 1/12/22 at 11:55 am with staff #15, Director of Clinical Services, she verified the above finding. When asked about family/MPOA involvement in treatment plan meetings, while referring to patient #15's record, staff #15 stated, "Down here in the treatment plan update that family wants 24 7 home care." When asked when that was discussed, with which family, staff #15 was unsure and stated, "This was close to when I first started so ..." When asked if there was another place family involvement was documented, staff #15 shook their head and stated, "It does say in here the family wanted help. We usually do a phone call with the family and they are part of the treatment team meetings we do once a week. In [patient #15's] situation, we would have just called the daughter. For those who don't have a MPOA, the patient makes that decision ... Looks like [patient #15] was only here for one treatment team that was in the chart and I wrote down that the family wants 24/7 homecare." She went on to say about the treatment team documentation, "It's not very specific. Who is involved, that remains still, the form is the same."

Based on record review, medical record review, and staff interview, the facility failed to ensure social service staff participated in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital.

Findings were:

Facility policy number MM-14 titled, "Reconciled Medications" stated in part, " PURPOSE: Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care.
POLICY:
Medication reconciliation applies across the continuum of care, this includes inpatients and outpatients. Medication reconciliation is a multidisciplinary process between Nursing, the Pharmacist, and the physician/non-:physician practitioner (NPP) with patient/family involvement.
PROCEDURE:
...Upon Discharge:
... 6. All discharge medication and instructions are explained to patient/family, the patient/family signs the discharge Medication reconciliation list and discharge transition record, then a copy is given to the patient/family, and the original placed in the patient's medical record. These instructions and list are also faxed (or otherwise provided) to the next level of care provider for continuity of care.
Patient instructions include how to take the medications prescribed, the time for the next dose and how long to take any new medications that may be prescribed. Instruct the patient to carry a list of his/her medications at all times and to present this list to all healthcare providers who are providing care to the patient, (i.e., pharmacist, primary care physician, follow-up care physician).
Patients and families shall be reminded to throw away old lists of medications, and to give all of their physicians and pharmacies the updated list of medications."

Facility policy number PC-18 titled "Discharge Planning: Transition Record" stated in part, " PURPOSE:
To establish guidelines for assisting patients to the appropriate level of psychosocial/ physical care, treatment and services for post-treatment placement, follow-up, and/or transfer.
POLICY:
Discharge planning commences upon admission to any program. Tentative discharge plans are established, reviewed, and modified throughout treatment.
PROCEDURE:
...2. Post discharge plans are reviewed and updated during weekly treatment team meetings, or more frequently as needed, to determine if the discharge plan meets the treatment needs of the patient.
3. Discharge planning should encompass the following areas:
*Review of the precipitating events and stressors which led to current
treatment and what resources the patient will need to deal with these
events/stressors post-discharge.
*Review of any daily living changes (need for nursing home, group home, home health, etc.) patient may need to decrease relapse potential.
*Review of community resources needs of patient post-discharge and
availability of same (i.e., vocational rehabilitation, private therapist,
educational, etc.)
*Family's needs post discharge.
*Patient/family's continued education needs.
*Cost feasibility of plan.
*Orders for continuing care to meet physical and psychosocial needs for discharge or transfer.

4. Social Services/Case Management personnel shall:
*Participate/facilitate discharge planning and develops mechanisms for exchanging information with service providers outside the facility.
*Obtain a signed release of information from the patient ( or guardian) for the purpose of providing the patient's continuing care instructions to the post-discharge referral source.
*Contact the post-discharge referral source to ascertain the suitability of placement, schedule any appointments, and to facilitate coordination of transfer.
*Coordinates transportation arrangements.
*Notifies patient and family of the date discharge will occur.
*Establishes communication with referral sources as needed to promote optimal transition of care, treatment, and services.
*When feasible, prior to discharge or transfer to a lower level of care,
conducts a discharge conference with patient (and family/significant others, as appropriate) to:
-Finalize living arrangements and post-treatment care plans to meet ongoing needs for care and services.
-Review patient progress in treatment.
-Discuss patient and family's expectations of patient's behavior and participation in recommended therapies post-discharge.

5. The Nurse shall:
*Review patient's medication regimen and educate on medications.
... *Upon discharge, provide the patient recommendations for anticipated
continuing care, treatment, and services and discharge medication
interventions.

6. The Treatment Team members will complete a crisis safety plan, if applicable, and document the final discharge plans on the Transition Record. This information shall include at a minimum:
...*Patient self-management instructions.
*Advance directive status and reason for not providing advance care
plan, if indicated.
*Surrogate decision maker, as applicable.
*24 hour/7 day contact information including physician for emergencies related to the inpatient stay.
...*Plan for follow up care including primary physician, other health care professional, or site designated for follow up, any/all follow-up
appointments and aftercare services.
*Valuables/belongings discharged to status ambulatory/accompanied by.
*Patient signatures of acceptance/understanding of recommendations
and Transition Record being provided to the next level of care
provider.

7. The Transition Record and any other documentation to support the continuum of care shall be transmitted to the next level of care provider within 24 hours of discharge and documented in the patient's medical record."


A review of the clinical record for Patient #15 revealed he was a 77-year-old male admitted to the facility on 5/25/21 at approximately 3:30 pm with admitting diagnosis of delusional disorder.
A nursing note dated 5/25/21 at 3:30 pm stated in part, "Pt has been inpatient at [acute care facility] since 5/14/21 dealing with multiple medical issues - Pt referred to Oceans as family is no longer able to care for pt at home as patient has become increasingly combative and aggressive - Pt reportedly pulled a knife out on son after son dismantled his car because pt was driving off and getting lost. Pt has been in 4 pt restraints while in the hospital because he has been so aggressive with staff - Pt reportedly had been having trouble with sleeping and tending to adls [activities of daily living]- Pt can benefit from treatment."

Consent for Involvement in Treatment for patient #15 dated 5/25/21 at 3:30 pm stated in part, "Family/Significant Other Consent & Authorization of Disclosure of Treatment [was checked]: I authorize the organization to acknowledge my presence and to discuss my treatment with the individual(s) listed below." Patient #15's daughter [also his MPOA], his son, and his caregiver were listed with phone numbers included. This was witnessed by two staff members

Patient #15's psychiatric evaluation dated 5/25/21 at 6:27 pm stated in part, " History of Present Illness: ... The patient is no longer able to care for himself in his home. His family would like him placed in a nursing home ... The patient has odd and delusional thinking. The patient is a poor historian .... He was not able to give reliable information ... The patient was disoriented to place, time, and situation ...
Plan: ...4) Social worker to work on discharge planning. The patient will need nursing home placement ...
Anticipated Disposition: Nursing Home"

Although it was clearly stated by the family and multiple behavioral health disciplines that Patient #15 needed aftercare services, the only nursing and "counseling" progress notes was the following:
Nursing note dated 5/26/21 at 4:00 pm stated in part, "Called daughter [MPOA] about patients [sic] decline, liver enzymes ALT/AST. Explained liver is shutting down and medical team has concluded patient is Hospice appropriate. Daughter agrees to hospice consult from [hospice facility]. She also requests help from therapy on how to get financial power of attorney. Informed therapy [staff #15] about request. [Hospice facility] notified and records requested for refferal [sic] sent."

Nursing note dated 6/3/21 at 7:00 pm stated, "Pt discharged to daughter, discharge papers given to daughter."

Inpatient Discharge Orders dated 6/3/21 at an unknown time stated in part, "Discharged to: [this was left blank]
...Activity: Requires assist with ADL's; Diet: [this was left blank]; Condition: stable; Prognosis: Poor." This was signed by the PMHNP-BC and psychiatrist at an unknown time.

Discharge medication reconciliation order/transition record dated 6/3/21 at 7:00 pm detailed Patient #15's medications to continue taking at home. The following was left blank: "Check as applicable: patient has enough medications to sustain prescribed amounts through next provider appointment. Prescriptions were called into ______ Pharmacy. Phone # ____." The section that stated "patient/patient representative instructed to updated the PCP when medications are discontinued, doses are changed, or new medications (including over the counter) are added and to carry this information in the event of emergency situations" was not checked to indicate this was addressed.
This was signed by the nurse and physician. There was no patient or patient representative signature.

A form entitled "Transition Plan and Continuity of Care Documentation," a 4-page form addressing discharge planning for patient #15 dated 6/3/21 at 7:15 pm stated in its entirety, "other documents/comments: Pt being released to family who will arrange after care.
Discharge Status: Scheduled
Discharge Disposition: home w/ fam
Home with family
Mode of Transport: Family member name/relationship: [daughter, MPOA's name]
Follow-Up Appointments: Family to make aftercare appts
Other Aftercare Services/Referrals: Tobacco Cessation Referral: N/A
Reason for Admission (Full description in two sentences or more): Aggressive, combative, confusion, refusing treatment, pulled a knife on son for disabling his car.
Principle Diagnosis at Discharge: F22
Major Procedures/Tests Performed During Hospitalization (Related to Diagnosis): Lab; Are there any lab or X-Ray results pending at discharge? No.
...24 Hour Contact Information for Records at Oceans Behavioral Hospital of: [left blank]; Number [left blank];
Additional Patient Instructions [left blank];
Patient Understanding of Discharge Plan: Patient/Family able to verbalize discharge instructions [was checked]
I have received a copy of my transition record, and I authorize a copy of my transition record, discharge medication list, and safety/crisis plan to be provided to my aftercare provider listed above for the purpose of ongoing treatment.
The patient has received a copy of the following: [none of these following areas were checked] discharge orders, crisis safety plan, dc medication reconciliation, pain management resources."
This was signed by the patient; the area for patient representative was left blank and unsigned. This was signed by the director of clinical services, a licensed professional counselor (LPC) staff #15 on 6/3/21 at 7:05 pm.

The Advance Directive/Healthcare Proxy Acknowledgement indicated the patient "has POA [Power of Attorney] to daughter;" however, the patient signed this form along with the director of clinical services, staff #15 on 6/3/21 at 7:10 pm

A "Crisis Safety Plan" dated 6/3/21 at 7:12 pm were filled in as follows, "Step 3: People and social settings that provide distraction:
1. Name family - son Phone _____
2. Name Home health Phone _____
3. Name hospice Phone ___

Step 4: People whom I can ask for help:
1. Name son - Willis Jr. Phone _____
2. Name Home health Phone _____
3. Name hospice Phone ___

Step 5: Professional or agencies I can contact during crisis:
1. Clinician/Agency Name Hospice Phone ____
Clinician/Agency Page or Emergency Contact # _______
2. Clinician/Agency Name Home health Phone ____
Clinician/Agency Page or Emergency Contact # _______

...Note: Keep this folded in your pocket as a quick reference
...Facility Name: Oceans Facility Phone Number: _____"


A review of the clinical record for Patient #17 revealed he was a 79-year-old male admitted to the facility on 5/20/21 with admitting diagnosis of delusional disorder. He was placed on violence/homicide precautions and falls precautions upon admission.

Patient nursing and "counseling" progress notes included the following:

Nursing note on 5/20/21 at 12:00 p.m. - "79 yr old married white male presents to Oceans on an Involuntary status ... Pt reportedly was in 4 point restraints while at the hospital as pt was severly [sic] paranoid believed he was being held hostage and even became physically aggressive at one point. Pt's family is not able to care for pt at home any longer as the patient is not 'safe' and recently suffered a fall about 3 weeks ago that has increased confusion and episodes of agitation ..."

Counseling note on 5/28/21 at 9:40 a.m. - "[Name] at [a skilled nursing facility] reports he was denied for admission due to if he had behaviors they don't have the staff to keep him safe. Called wife - [name omitted], she is okay with trying [another facility] ..."

The note above was the only counseling/clinical services narrative progress note in the patient record. No additional notes regarding the discharge placement of Patient #17 were found in the record. A final nursing note on 6/3/21, date of discharge, at 8:45 p.m. read as follows:
"Escorted pt to vehicle. Pt discharged to wife and son. Assisted pt into vehicle, discharge papers given to son medications need to be called in to pharmacy in AM."
A form entitled "Transition Plan and Continuity of Care Documentation" was a 4-page form addressing discharge planning. Only the following sections were completed, including staff entries in their entirety:
"Other Documents/Comments: 'Pt to be released to family who will find him a nursing home.'"
"Discharge Disposition: home ... Home with 'son and wife'"
"Follow-Up Appointments ... Name/Facility ... 'Family to find nursing home.'"
"Reason for Admission (Full description in two sentences or more): 'Pt fell which increased dementia symptoms, agitated, aggressive. He was confused.'"

The document was signed by the patient and a LPC on 6/3/21 at 6:48 p.m.

A "Crisis Safety Plan" on 6/3/21 at 6:51 p.m. included a section entitled, "Professionals or agencies I can contact during crisis." Two resources were filled in as follows:
"1. Clinical/Agency Name 911 Phone_______________________________
2. Clinical/Agency Name Oceans Phone _______________________________"

The form had no signature of either the patient or facility staff.

In an interview on 1/12/22 at 11:25 am with Director of Clinical Services, LPC, staff #15, when asked about the discharge planning for patient #15, staff #15 stated, "The things we suggested they could do, [MPOA] didn't want those things. We tried to get him in hospice because we felt like he needed it. I want to say his kidney function was going wrong and his daughter did not want us to do that [send him to hospice], so we couldn't make those referrals." When asked how he was discharged, she stated, "[MPOA] said she was coming up from Austin today and came up there and took him ... Family told us she basically dropped off with a brother who couldn't come get him [from the facility]."
When asked why Patient #15's discharge paperwork was not signed by the MPOA, she stated, "She would not come, she basically wanted him to come down to the car." When asked who went over the discharge information with the patient, she stated, "Myself at that time." When asked why there was no aftercare set up for Patient #15, she stated, "Because they [the family] didn't want any, they wanted the 24-7 care and that is it." When asked if she discussed other options for after care, she stated, "Yes, but she just wanted 24 7 care. That was it." When asked if his discharge medications were discussed with the family, she stated, "Yes, for him it would be where the nurse discussed the med rec," [which had no family signature]. When asked if the only area where discharge instructions were acknowledged by the patient/family, she stated, "The appointments, but he didn't have any, so it would be in the med recs where the nurse discussed with the family ... I don't think I see that in here." When asked if she discussed discharge information with the family, she stated, "No, because I was not allowed to speak with them anymore."
When asked how the medical record shows how the facility worked to find the patient aftercare, she stated, "I started in the middle of April, this was the end of May - we are doing that now. If the family has stopped us from doing certain things, we document that in our notes."

When asked if they would have a confused patient with a MPOA sign their own consents, she stated, "With a MPOA normally no, but we did it with him because the daughter refused to come." When discussed this was not documented, she stated, "Yes, right."
Staff #15 confirmed the facility did not follow discharge planning policy and failed to show they worked with the families for the aftercare of Patients #15 and #17.

In an interview on 1/12/22 at 9:59 am with the DON, staff #4, when asked about the discharge planning for Patient #15, she stated, "We finally got to the point where we discharged home to her [MPOA]; she was supposed to be giving him 24-hour care before he goes to hospice ... that wasn't 24 hour care. We expressed to her that she needs to have 24-hour care. She was very aware he could not be left alone. She left the patient at home. He had a catheter, fell shortly after that [discharge] they sent him to the ER and he passed after that. We definitely stressed to her how important that was [24-hour care]. The department of energy social workers came out here several times. It should be in the pink notes." She looked through and could not find any. When discussed there was no documentation related to discharge planning with the family, she looked through the chart and stated, "Here's my note about the daughter." She read it aloud. When pointed out the daughter was asking for help, she stated, "Yes, I know ... when we would say, 'Hey, how about this group home,' she would shut it down. She said, 'I don't want that.'" When discussed the charting does not reflect appropriate discharge for this patient. She stated, "I understand."