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Based on observation, interview with the Chief Nursing Officer and review of medical records it was determined the hospital placed patients in the Intensive Care Unit until a bed was available on the Adult Psychiatric unit or the PPS (Prospective Payment System) excluded Geriatric unit. This included patients who were committed through the probate court system. This had the potential to affect all patients served by the hospital and did affect Patient Identifier (PI) # 10, # 11, # 12,# 13, # 14, # 15, # 16, # 17, # 18, # 19, # 20, # 21, # 22, # 23, # 24, # 25, # 6, # 8 and # 26.

Findings Include:

The surveyor reviewed a memo from the Chief Nursing officer dated 4/14/11 to the New Day Behavioral Health Staff regarding admissions. The memo included, "When there are no available beds on the Behavioral Health Unit and a physician or referral source calls with an admission, take down the information from the physician and inform the physician the Behavioral Unit is full, so the patient will be admitted to the Intensive Care Unit (ICU) until a bed is available on the Behavioral Unit. After informing the physician, contact the Nursing Supervisor with the information."

On 7/12/11 the surveyor observed in the Adult unit at 8:45 AM, there were 14 patients in the group room. There were 12 patients on the PPS excluded Geriatric unit. At 9:00 AM the surveyor asked Employee Identifier (EI) # 6, a Licensed Practical Nurse preparing medications who the medications were for? EI # 6 stated that she had brought the patients down from ICU and would be giving their medications. The surveyor asked how many patients she had brought down and she stated, 3. Two patients on the adult side and 1 on the PPS excluded Geriatric side. This brought the census on the Geriatric PPS unit to 13. The unit is certified and approved for only 12 beds.
Medical Record findings:

1. PI # 10 was admitted 6/22/11 to ICU bed # 2 and transported to the Geriatric unit during the day for group therapy and therapeutic activities and returned to the ICU between 7:00-8:00 PM for the night. PI # 10 was transferred to room 112 B on the Geriatric unit 6/24/11.
The patient had a prior admission 6/16/11 through 6/17/11. The chief complaint on this admission was, "Severe depression, psychotic and suicidal thoughts."
The patient had an Axis I diagnosis of Bipolar disorder, depressed type. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, "... admitted to the hospital as she is very depressed, insomniac, becoming agitated and restless, and not responding to outpatient treatment given, and escalating."

2. PI # 11 was admitted to ICU bed # 5 on 6/20/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 11 was transferred to room 119 B on 6/22/11.
The patient had an Axis I diagnosis of Major depressive Disorder, recurrent. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital from the ... Nursing Home as he has been getting depressed, hopeless and helpless. "

3. PI # 12 was admitted to ICU bed # 3 on 6/20/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 12 was transferred to room 119 A on 6/22/11.
The patient had an Axis I diagnosis of Chronic Undifferentiated Schizophrenia. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as he has been having an exacerbation of his chronic schizophrenia, talking to himself, talking out of his head, having pressured speech and escalating. "

4. PI # 13 was admitted to ICU bed # 2 on 6/9/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 13 was transferred to room 119 B on 6/11/11.
The patient had an Axis I diagnosis of Alzheimer ' s with behavioral disturbances. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as she has been acting somewhat confused, not responding to treatment given and escalating. "

5. PI # 14 was admitted to ICU bed # 5 on 6/7/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 14 was transferred to room 109 on 6/9/11.
The patient had an Axis I diagnosis of Dementia Alzheimer ' s type with Psychosis and Major Depressive disorder. No Axis II Diagnosis. The chief complaint documented on the admission history and physical included, " My daughter controls all of my money and changed my will. "

6. PI # 15 was admitted to ICU bed # 2 on 7/5/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 15 was transferred to room 128 on the Adult Psychiatric unit 7/7/11. The patient was then transferred to the medical floor on 7/9/11 where he was treated for Atrial Fibrillation and the transferred to 115 B on the geriatric unit 7/12/11.
The patient had an Axis I diagnosis of Schizophrenia, paranoid type. Rule out schizoaffective disorder. Rule out bipolar I disorder, most recent episode manic. Axis II Diagnosis deferred. The history of present illness on the admission history and physical included, " ... a significant history of psychiatric illness who now lives in a group home on account of his psychiatric problems, unable to take care of himself. He states he was sent here due to inappropriate sexual behavior at the group home. He has a past psychiatric history of schizophrenia and bipolar disorder ... "

7. PI # 16 was admitted to ICU bed # 6 on 5/6/11 and transferred to room 111 on the Geriatric unit 5/7/11.
The patient had an Axis I diagnosis of Bipolar mood disorder with psychotic symptoms. Alcohol dependence and alcohol withdrawal symptoms. Axis II no diagnosis. The history of present illness on the admission history and physical included, " The patient with chronic psychiatry history. He has been treated for depression and anxiety. He came to the ER (emergency room) with a chief complaint of ' I want to kill myself ' . He has been binge drinking and initially in the ER his blood alcohol was 0.26. He was reporting suicidal ideation.

8. PI # 17 was admitted to ICU bed # 2 on 6/4/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 1 was transferred to room 119 B on the Geriatric unit 6/7/11.
The patient had an Axis I diagnosis of Bipolar disorder, depressed type. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as she has been very depressed, not sleeping and despondent and she has been admitted to get ECT (electroconvulsive therapy) treatments to see if this is going to help her as she has a very depressed condition. "

9. PI # 18 was admitted to ICU bed # 5 on 5/15/11 and transferred to 119 B on 5/16/11.
The patient had an Axis I diagnosis of Cognitive disorder, not otherwise specified. Mild cognitive impairment. Adjustment disorder with depressed mood. Rule out vascular dementia. No Axis II Diagnosis. The history of present illness documented on the admission history and physical included, " The patient reports that she has been having fatigue and sleep difficulties. She is reporting symptoms of anxiety and concerns about the future. She is having some difficulty with her memory ... "
The patient had a diagnosis of adjustment disorder and going between two units was not the best plan for treatment.

10. PI # 19 was admitted to ICU bed # 5 on 5/16/11. The patient was transferred to the Geriatric unit 5/17/11 at 8:00 AM.
The patient had an Axis I diagnosis of chronic paranoid schizophrenia with acute exacerbation. No Axis II Diagnosis. The history of present illness documented on the admission history and physical included, " Noncompliant with his medications lately. As such he has become increasingly psychotic with paranoia, delusions and hallucinations ... "
The patient was referred by the probate court.
The patient progress notes dated 5/17/11 documented, " 9:30 AM patient escorted back to ICU to have EKG (electrocardiogram) and UA (urinalysis) performed. Patient not cooperative. Refused to have EKG performed times two. Patient stated he refused to return to New Day Adult. Nursing supervisor notified and he spoke with patient for patient to allow EKG to be performed and to return to New Day. Patient refused to give urine specimen. Patient notified to let staff know when he needs to void and we would give him a cup and he would not speak to staff. Began using profanity and putting shoes back on. "
The patient progress notes dated 5/17/11 documented, " 10:00 AM patient escorted to New Day and to smoke. "
The patient progress notes dated 5/17/11 documented, " 12:00 AM patient sitting in day room eating lunch with group ... "
The patient progress notes dated 5/17/11 documented, " 13:30 PM patient sitting in day room falling asleep. "
The patient progress notes dated 5/17/11 documented, " 15:33 PM patient visited by physician. " No indication if this was in the ICU or on the psychiatric unit.
The patient progress notes dated 5/17/11 documented, " 16:40 PM patient escorted to New Day Geriatric unit. Patient ambulates without difficulty. No complaints at this time. Patient still withdrawn and quiet. Does not answer many questions that are asked ... "
The patient progress notes dated 5/17/11 documented, " 16:45 PM patient received to room 107, oriented to room, unit. No changes in patient assessment. "

11. PI # 20 was admitted to ICU bed # 3 on 5/21/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 20 was transferred to room 114 B on the Geriatric unit 5/23/11.
The patient had an Axis I diagnosis of Schizoaffective disorder, bipolar type. Vascular dementia, mild. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital from her home as she has been acting confused, withdrawing, not talking and escalating. " The history of present illness documented on the admission history and physical included, " ... a long-standing history of psychiatric problems related to schizoaffective disorder, has been in and out of state hospitals, mental health centers ...has taken antipsychotics with good response. "

12. PI # 21 was admitted to ICU bed # 3 on 6/17/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 21 was transferred to room 224 on the Medical unit 6/21/11 four days after her admission.
The patient had an Axis I diagnosis of Schizoaffective disorder, bipolar type. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as a transfer from ... as she has been acting confused, apparently has been falling out, having difficulties with her health and due to agitation and confusion she was admitted for further evaluation and treatment. The patient was not housed in the psychiatric unit with trained staff in mental illness to assess the patient's needs and develop the treatment plan for four days.

13. PI # 22 was admitted to ICU bed # 6 on 6/23/11 and remained there until 1450 when she was ambulated to the Geriatric unit. On 6/25/11 she was on the census in room 114 A, the Geriatric unit.
The patient had an Axis I diagnosis of Psychotic depression, consider bipolar disorder with psychosis. Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as a lady who is confused, depressed and cannot think straight, as she says. "

14. PI # 23 was admitted to ICU bed # 3 on 7/7/11 and transferred to 112 A on 7/8/11.
The patient had an Axis I diagnosis of Schizoaffective disorder, depressed type. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as she has been getting depressed, isolating, hearing more voices and escalating. " The history of present illness documented on the admission history and physical included, " ... she leaves home at midnight and crosses major highways without looking, getting confused, blaming others, accusing others and feels like someone is putting a curse on her. She is very paranoid indeed and this patient is not responding to the treatment and for this reason was admitted. "

15. PI # 24 was admitted to ICU bed # 5 on 7/9/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 24 was transferred to room 112 B on the Geriatric unit 7/13/11, four days after her admission.
The patient had an Axis I diagnosis of Paranoid Schizophrenia. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as requested by her guardian as this patient has been becoming suspicious, paranoid, refusing treatment, escalating and not responding to the treatment given. "

16. PI # 25 was admitted to ICU bed # 2 on 6/24/11 and remained there, only being transported to the Adult unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 25 was transferred to room 105 B on the general floor 6/27/11. This 29 year old patient remained on the General floor from 6/27/11 through 6/30/11 when she was moved to the Adult psychiatric unit room 131.
The patient had an Axis I diagnosis of Bipolar disorder, mixed. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ...readmitted to the hospital as she has been feeling depressed again, not responding to the outpatient treatment given and escalating. "

17. PI # 6 was admitted 6/4/11 to ICU bed # 3 under a court order. There was no bed available on the Adult Psychiatric Unit. The patient was transported from the ICU to the Psychiatric unit during the day for therapeutic group and activities through 6/6/11 when the census shows her in room 127, the seclusion room. The patient had an Axis I diagnosis of Depression. The patient remained in room 127 until 6/15/11 when the census shows him/her in the ICU room # 2. The patient was discharged 6/15/11 from the ICU bed. The seclusion room did not have a call system and the door would lock if closed. To open the door to room 127, the staff entered by way of the key pad on the door, the only surveillance in the room was the small ante-room where a camera was located and the mattress would be placed on the floor.

18. PI # 8 was admitted to ICU bed # 4 on 6/24/11 and transferred to room 127, the seclusion room on 6/25/11. The patient had an Axis I diagnosis of Depressive disorder with psychotic features, schizoaffective disorder or bipolar disorder depressed type with psychosis. No Axis II Diagnosis. The patient was under court order.

19. PI # 26 was admitted to ICU bed # 3 on 5/13/11 and remained there, only being transported to the Adult unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 26 was transferred to room 131 on 5/15/11.
The patient had an Axis I diagnosis of Bipolar disorder, by history. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " He lives with his mother and is referred for this admission by the Probate Court ... " Chief Complaint: " Psychotic and suicidal. "

20. . PI # 32 was admitted to ICU bed # 4 on 7/11/11 .The patient was transferred to the Adult psychiatric unit room 132 A on 7/12/11 at 8:30 AM.
The patient had an Axis I diagnosis of Bipolar Disorder depressed type.

Summary:

There were a total of 90 patients admitted to Intensive care unit beds, transported back and forth during the day to either the Geriatric unit or the Adult unit. The Adult unit does not have bathroom facilities or a place for the patient to rest if needed and must be transported back through the hospital and back up the elevator and down a hall to the ICU for rest or toileting.
There was no policy in place for admitting to ICU, no policy regarding moving the patients back and forth through the hospital from a second floor unit to the locked psychiatric unit, no direction as to how many patients one person could transport either by wheelchair or ambulation. The patient was to receive their medications and all meals on the psychiatric unit and the ICU staff member documented on their medical record.

During an interview with Employee Identifier (EI) # 1, the Chief Nursing Officer, on 7/12/11 at 12:15 PM, EI # 1 explained the reason and process for admission to the Intensive Care unit as follows, " There ' s a crisis of overflow patients, units are full and the psychiatrist feels they need in patient care. Admit them to ICU to be watched closely, close circuit monitor/camera to observe ...Dr ... said patients were missing care and recommended they go down to the units to participate in group activities. "

The surveyor asked EI # 1 what the usual routine was for the day if patients were housed in ICU beds. EI # 1 explained, " They eat there (psychiatric units), have visitors in the day room, doctor sees them there and they participate in groups. If they need to they take them back to ICU to nap, use the bathroom. If ICU is full and both units we use the seclusion room and a MHT (mental health tech) is assigned to monitor the room. "

The surveyor asked how the staff was assigned to cover both the psychiatric unit and the ICU if ICU medical patients were in the unit. EI # 1 explained, " Two nurses are always assigned to ICU- 1 nurse for medical or critical care, if more is needed we have to call in a nurse for the psychiatric patients. ICU nurses are trained in psych care the SECURE program (a program to control and deescalate patients with behavior problems). " The interview concluded at 12:30 PM on 7/12/11.

In a telephone interview with EI # 1 on 7/22/2011 at 2:12 PM, the surveyor asked, " Do the nightshift nurses in ICU have any training or experience in dealing with psychiatric patients ?" EI # 1 replied, " No mam."

The safety of patients housed in the Intensive Care Unit could be compromised due to the medical equipment installed for care of acutely ill medical patients, cardiac monitoring devices and numerous electrical wires necessary to provide care for critically ill patients.

The transport of patients through the hospital from a second floor open ICU down a public elevator and down another hall to a locked psychiatric unit can pose problems with safety for other patients in the ICU, general second floor medical patients, staff who are not trained to work the mentally ill patients and the public who have access to the common areas where psychiatric patients are transported.

The Intensive Care Unit can be an active place during the night hours which could interfere with the patient's rest both for the psychiatric patients and the medical patients.

Based on observation, an interview with the Chief Nursing Officer and review of medical records it was determined the hospital placed patients in the designated seclusion room to be utilized as a regular patient room without orders and documentation to clarify the door to the seclusion room was disarmed or unlocked while the patients were present. This affected Patient Identifier (PI) # 1, 2, 3, 4, 5, 6, 7, 8 and 9.

Findings include:
On 7/12/11 at 10:30 AM the surveyor toured the seclusion room # 127 with one of the Registered Nurses, Employee Identifier (EI) # 5, working the Adult Psychiatric unit. The surveyor observed a hospital bed with linens in the room and a smaller room with a window with the camera inside and a mattress on the floor for the actual seclusion patient to be placed. The surveyor asked EI # 5 why there was a regular hospital bed in the room and had they been placing patients in this room as a regular room. EI # 5 stated, " Oh no. "

On 7/12/11 the surveyor reviewed the census for May 2011 and observed room 127 with patients assigned. On 7/12/11 at 11:15 AM, Employee Identifier # 1, the Chief Nursing Officer was asked about patients being assigned to room # 127. EI # 1 confirmed the room had been used to place patients when no other bed was available. The surveyor asked if the door was locked when the patients were in room # 127. EI # 1 stated that she thought a Mental Health Technician was assigned to sit by the door but she could not say that there was always someone by the door. The seclusion room did not have a call system and the door would lock if closed. To open the door to room 127, the staff entered by way of the key pad on the door, the only surveillance in the room was the small ante-room where a camera was located and the mattress would be placed on the floor.

1. PI # 1 was admitted 5/3/11 to room 127, the seclusion room. The patient had an Axis I diagnosis of Intermittent Explosive disorder and Psychosis, Not Otherwise Specified and an Axis II diagnosis of Mental Retardation. The patient remained in room 127 through 5/9/11 when he/she was discharged. There was no order to place the patient in a seclusion room in the medical record.

2. PI # 2 was admitted 5/10/11 to room 127, the seclusion room. The patient had an Axis I diagnosis on admission of Suicide Attempt overdose with insulin, Depression and Anxiety. The discharge diagnosis for Axis I was Major Depression with Anxiety Symptoms, Panic Disorder, Cocaine Dependent and Cocaine induced mood and anxiety symptoms. No Axis II diagnosis. The patient remained in room 127 through 5/18/11 when he/she was discharged. There was no order to place the patient in a seclusion room in the medical record.

3. PI # 3 was admitted 5/16/11 to ICU (Intensive Care Unit) because there was no bed available on the Adult Psychiatric Unit. The patient was transferred to room 127, the seclusion room 5/18/11. The Axis I diagnosis on admission was Bipolar I disorder, most recent episode mixed, Cocaine Dependence and Cocaine induced mood disorder and Cocaine induced psychiatric disorder. No Axis II Diagnosis. The patient remained in room 127 from 5/18/11 through 5/20/11 when he/she was discharged. There was no order to place the patient in a seclusion room in the medical record.

4. PI # 4 was admitted 5/18/11 to room 132 A with an Axis I diagnosis of Schizoaffective Disorder, Bipolar type. No Axis II Diagnosis. The patient came in with depression and hallucinations. The patient was transferred to room 127, the seclusion room 5/21/11 and remained there until 5/25/11 when he/she was placed in room 121 until discharged on 5/27/11. There was no order to place the patient in a seclusion room in the medical record.

5. PI # 5 was admitted 5/25/11 to room 127, the seclusion room. The patient had an Axis I diagnosis of Depression. No Axis II Diagnosis. The patient remained in room 127 through 5/30/11 when he/she was discharged. There was no order to place the patient in a seclusion room in the medical record.

6. PI # 6 was admitted 6/4/11 to ICU bed # 3 under a court order. There was no bed available on the Adult Psychiatric Unit. The patient was transported from the ICU to the Psychiatric unit during the day for therapeutic group and activities through 6/6/11 when the census shows her in room 127, the seclusion room. The patient had an Axis I diagnosis of Depression. The patient remained in room 127 until 6/15/11 when the census shows him/her in the ICU room # 2. There was no order to place the patient in a seclusion room in the medical record. The patient was discharged 6/15/11 from the ICU bed.

7. PI # 7 was admitted 6/15/11 to room 127, the seclusion room and remained until his/her discharge 6/24/11. There was no history and physical or discharge summary available for review while the surveyor was onsite.

8. PI # 8 was admitted to ICU # 4 on 6/24/11 and transferred to room 127, the seclusion room on 6/25/11. The patient had an Axis I diagnosis of Depressive disorder with psychotic features, schizoaffective disorder or bipolar disorder depressed type with psychosis. No Axis II Diagnosis. The patient was under court order. He/she remained in room 127 through 6/27/11. There was no discharge summary available for review while the surveyor was onsite. There was no order to place the patient in a seclusion room in the medical record.

9. PI # 9 was admitted to room 127, the seclusion room and remained until 7/9/11 when he/she was placed in room 124. The patient had an Axis I diagnosis of Bipolar Disorder, Depressed type. No Axis II Diagnosis. The patient was discharged 7/10/11. There was no discharge summary available. There was no order to place the patient in a seclusion room in the medical record.
There was no order for the use of the seclusion room as a therapeutic treatment in any of the information provided to the surveyor for Patient Identifier # 1, 2, 3, 4, 5, 6, 7, 8 and 9 who were placed in seclusion during this time frame.

Based on interview with Employee Identifier (EI) # 1, the Chief Nursing Officer (CNO) and medical record review it was determined in 1 of 1 patient records reviewed with a wound that the orders were not followed as written and when the wound care orders were changed by the physical therapist they were not put in writing for the physician signature or for nursing staff to know what wound care was to be provided. This affected Patient Identifier (PI) # 27.

Findings include:

1. PI # 27 was admitted to the hospital 7/1/11 with diagnoses of Dementia with behavioral disturbances, Hypertension, Anemia, Arthritis, status post fractured spine and status post gastrostomy (G) tube removal 6/30/11.

A verbal order was written 7/1/11 at 6:30 PM to clean the right heel with normal saline, apply TAO (topical antibiotic ointment) and cover with Kling every HS (hour of sleep). Clean G-tube insertion site with normal saline and cover with 4x4 gauze every HS.

The patient progress note date 7/1/11 documented at 5:00 PM, "...Ulcer to back of right heel and g tube insertion site where tube was removed 6/30/11. No s/s (signs/symptoms) infection noted to either area."

The patient progress note date 7/1/11 documented at 9:10 PM, "Healing ulcer right heel with Duoderm in place." There was no order for Duoderm and the wound care ordered was not provided.

The patient progress note date 7/2/11 documented at 10:11 AM, " Healing ulcer right heel. Dressing D & I (dry and intact) to abdomen from G tube removal on 6/30/11. No s/s infection." There was no documentation of what type of dressing was on the heel or if wound care was provided as ordered 7/1/11.

The patient progress note date 7/3/11 documented at 7:30 AM, "Approximating ulcer an inch long on right heel. No s/s of infection or drainage. Dressing dry, intact 3-4 mm ( millimeter) puncture site from G tube on abdomen, no s/s infection." There was no documentation of what type of dressing was on the heel or if wound care was provided as ordered 7/1/11.


The patient progress note date 7/4/11 documented at 5:15 PM, " Old G tube site, ulcer healing L/( left) heel Duoderm in place for protection." There was no documentation if wound care was provided as ordered 7/1/11 and the ulcer was on the right heel.

The patient progress note date 7/5/11 documented at 8:00 PM, " Old G tube site, ulcer healing on R (right) heel." There was no documentation of what type of dressing was on the heel or if wound care was provided as ordered 7/1/11.

The patient progress note date 7/6/11 documented at 09:10 AM, " Healing ulcer to right heel. No drainage, odor, or any other s/s infection noted to either area." There was no documentation of what type of dressing was on the heel or if wound care was provided as ordered 7/1/11.

The patient progress note dated 7/7/11 documented at 09:20 AM, " Healing ulcer to back of right heel with no drainage, odor or other s/s infection noted." There was no documentation of what type of dressing was on the heel or if wound care was provided as ordered 7/1/11.

The patient progress note date 7/8/11 documented at 8:55 PM, " Dressing to right heel removed due to getting wet in shower. Area pink with yellow tissue present. Area cleaned with wound cleanser, 4x4's applied to site. Wrapped with Kling." This was not the wound care ordered 7/1/11.

A verbal order was written 7/9/11 at 6:00 PM to have PT (physical therapy) to evaluate right heel ulcer.

The patient progress note date 7/9/11 documented at 7:46 PM, "Right heel ulcer noted with dressing dry and intact."

The patient progress note date 7/10/11 documented at 08:00, "Right heel ulcer being treated per PT." The patient progress note date 7/10/11 documented at 8:33 PM, "Dressing dry and intact to right heel. Dressing to be done per PT."

The physical therapist evaluated the patient's wound 7/10/11 and documented the following, " Right heel dressing removed. Wound on posterior medial right heel and measured 2 x 0.8 cm( centimeters) L x W and .3 cm deep, with small undermining distal wound of approximately 0.2 cm. Wound bed 80% red/ 20 % yellow. Wound was derided with tweezers and 4 x 4/ NS( normal saline) of small amt (amount) yellow exposing red wound bed. Drainage was serous. No outward sign of infection."

The PT failed to document if wound care was provided or to document any order for a type of wound care or the frequency the wound care would be provided.

The PT progress notes dated 7/11/11 documented the LPTA (licensed physical therapy assistant), " Removed old dressing with no drainage, cleaned with Carraklenz covered with Santyl, Telfa, Kling and Coban. Pt ( patient) with 100% yellow wound." There was no order for the wound care provided by the LPTA.

Santyl ointment is an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level as defined by the 2011 Healthpoint Biotherapeutics.

There was no documentation of wound care being provided 7/12/11 by the physical therapist and no further documentation from the physical therapist in the medical record when reviewed 7/14/11 at 9:00 AM by the surveyor.
The patient was discharged 7/13/11 to be followed by home health services, there were no orders in the medical record for wound care after the initial order written 7/1/11.

In written interview questions to the Chief Nursing Officer, EI # 1 and the Quality Assurance Director EI # 2, 7/14/11 at 10:45 AM, the surveyor asked why the wound care ordered was never documented, why the wound was not measured until 7/10/11 and why the physical therapist did not document wound care and an order for the staff to follow.

On 7/15/11 at 9:50 AM, EI # 1, the CNO responded in a telephone interview to the surveyor. EI # 1 stated that the patient arrived from home with Duoderm and the night nurse found the Duoderm and kept using it, that the order from 7/1/11 was just missed. EI # 1 confirmed the therapist failed to document and order for the wound care, failed to document he provided wound care and failed top document instruction for the LPTA to follow.

Based on a review of treatment plans in medical records, review of policies and procedures and interview with the Chief Nursing Officer it was determined the treatment plan was not signed as a plan from the treatment team and not updated as needed when the patient had changes in their condition. This had the potential to affect all patients served by the PPS(Prospective Payment System) excluded psychiatric unit and the adult psychiatric patients. This did affect PI # 28, # 24, # 30, # 31, and # 19.

Agency policy : Treatment Planning

Purpose: To provide a plan of care that is individualized and specific to the needs of the patient.
Policy: Each patient shall have an individualized treatment plan based on the patient's presenting problems, emotional and behavioral status, physical health, strengths and weaknesses. The multidisciplinary treatment plan (MTP) should be derived from each discipline's assessment of the patient and the patient/family perceptions of patient's needs.
Each discipline is responsible for documenting his/her role and interventions in the plan of care.

The MTP should be completed by the third (3) day of treatment.

Each problem should have a short and a long term goal. Goals should indicate a target date for accomplishment and should be stated in positive terms.

The MTP should be reviewed at least weekly by the treatment team.

Each discipline should add their specific interventions following their initial assessments of the patient.

Medical record findings:

1. PI # 28 was admitted to the PPS excluded Geriatric psychiatric unit 7/5/11 with an Axis I diagnosis of Dementia of the Alzheimer's type with behavioral disturbances, Rule Out Vascular Dementia and Adjustment Disorder with Depressed Mood.

The Master Treatment Plan was dated 7/5/11 with a presenting problem of mixed dementia with behavioral disturbance and depression. No patient assets or patient disadvantages were marked on the form.
Problems/Behavior:
Problem # 1- 7/5/11 Depression
Problem # 2- Confusion
Problem # 3- Aggressive Behavior
Problem/ Physical:
Problem # 1- Falls

There was no discharge planning marked on the form. There was no signature to show involvement of the family or the patient. The physician nor the primary therapist had signed the form. The form was signed by the registered nurse on 7/5/11; the activity director and the social worker signed and dated the form 7/6/11. There were no short term or long term goals documented and no date for a planned response to care. The weekly treatment team reviews were not documented or available to the surveyor while onsite on 7/14/11.
There were no recreational/ activity notes on the medical record and the only counselor notes were dated 7/6/11, 7/7/11 and 7/8/11.

Written interview questions were presented to Employee Identified (EI) # 1 the Chief Nursing Officer on 7/13/11 at 3:30 PM regarding the treatment plan and missing documentation of group/ activity notes. On 7/14/11 at 10:50 AM, EI # 1 explained that the counselor was out sick 7/11/11 and no group was held and at this time they only had group 5 times a week. EI # 1 also stated that the activity director states that she was behind on her notes.

2. PI # 24 was admitted to ICU (intensive care unit) bed # 5 on 7/9/11 and remained there, only being transported to the Geriatric unit during the day for group therapy and therapeutic activities. Then, returned to the ICU between 7:00-8:00 PM for the night. PI # 24 was transferred to room 112 B on the PPS excluded Geriatric unit 7/13/11 four days after her admission.
The patient had an Axis I diagnosis of Paranoid Schizophrenia. No Axis II Diagnosis. The identifying data documented on the admission history and physical included, " ... admitted to the hospital as requested by her guardian as this patient has been becoming suspicious, paranoid, refusing treatment, escalating and not responding to the treatment given. "
The Master Treatment Plan was dated 7/9/11 with a presenting problem of paranoid delusions and verbal aggression. No patient disadvantages were marked on the form.
Problems/Behavior:
Problem # 1- 7/9/11 delusions, verbal aggression
Problem/ Physical: nothing was documented

The only signature on the form was the registered nurse. The patient nor family had signed, no physician, counselor, social worker, or activity/recreational director signature was on the form within the 72 hours required by policy to complete.
A second Master Treatment Plan was present with no date which listed the presenting problem of paranoid behavior and medication noncompliant, hallucinations, auditory and visual, patient seeing dead mother.
The only signature on the form was the registered nurse and the patient. There was no physician, counselor, social worker, activity/recreational director signature on the form within the 72 hours required by policy to complete.
Written interview questions were presented to Employee Identified (EI) # 1 the Chief Nursing Officer on 7/13/11 at 3:30 PM regarding the treatment plan missing signatures and two incomplete treatment plans being presented to the surveyor. On 7/14/11 at 10:50 AM, EI # 1 stated that she did not know why the plan was not complete and the staff thought she did not have a treatment plan so a different nurse started one when they had the weekly meeting.

3. PI # 31 was admitted to the PPS excluded Geriatric psychiatric unit 5/18/11 with an Axis I diagnosis of Schizophrenia, schizoaffective type with features of catatonia, psychosis and depression.

The Master Treatment Plan was dated 5/19/11 with a presenting problem of Patient wanders and is anxious with restlessness. No patient disadvantages were marked on the form.
Problems/Behavior:
Problem # 1- 5/19/11 anxious/ restless/ psychosis
Problem/ Physical:
# 2-5/19/11- CAD ( coronary artery disease)
# 3-5/19/11- Hypothyroidism
# 4- 5/19/11- CRF ( chronic renal failure)

The form was signed by the physician, registered nurse, counselor and patient on 5/24/11. The social worker and the activity/ recreational director failed to sign and participate in the treatment plan. This plan was completed 5 days after admission and not with in the 72 hours per policy.

The patient was moved 4 times in her hospitalization. She was on the Geriatric unit 5/18/11, moved 5/20/11 to another geriatric bed then moved to the adult psychiatric unit 5/21/11 and back to the geriatric side 5/27/11.

Written interview questions were presented to Employee Identified (EI) # 1 the Chief Nursing Officer on 7/13/11 at 3:30 PM regarding the treatment plan missing signatures and being completed 5 days after admission. On 7/14/11 at 10:50 AM, EI # 1 stated that the nurse manager on the adult side did not realize the treatment plan was to be completed in 72 hours.

4. PI # 30 was admitted to the Adult psychiatric unit 5/18/11 with an Axis I diagnosis of Schizoaffective disorder depressed type with mild cognitive impairment.

The Master Treatment Plan was not dated. The presenting problem the patient stated, " I got in an argument with my roommate. She thought I stole her money. Then everybody at the group home got mad at me." No patient disadvantages were marked on the form.
Problems/Behavior:
Problem # 1- 5/18/11 Depression
Problem # 2- 5/18/11 Aggressive behavior
Problem/ Physical:
Seizure HX ( history).

There was no discharge planning documented on the form.

The patient, registered nurse and activity/recreational director signed the form 5/18/11. The physician, counselor and social worker signed the form 5/24/11; 6 days after admission.

The patient had documented behavior issues 5/21/11, 5/22/11 and 5/23/11 requiring Geodon 20 mg (milligrams) intramuscular. There was no updates or changes to the treatment plans. The patient was discharged back to the group home 5/26/11.

Written interview questions were presented to Employee Identified (EI) # 1 the Chief Nursing Officer on 7/13/11 at 3:30 PM regarding the treatment plan missing signatures, being completed 6 days after admission and no updates even though the patient had documented behavior issues. On 7/14/11 at 10:50 AM, EI # 1 stated that the nurse manager on the adult side was not aware of the 72 hours time frame for completion of the treatment plan.

5. PI # 19 was admitted to ICU bed # 5 on 5/16/11. The patient was transferred to the Geriatric unit 5/17/11 at 8:00 AM.
The patient had an Axis I diagnosis of Chronic paranoid schizophrenia with acute exacerbation.
The Master Treatment Plan was dated 5/16/11. The presenting problem: " Court order by ... County... direct admit...Schizophrenia with hallucinations and elevated B/P ( blood pressure)." No patient assets were marked on the form.
Problems/Behavior:
Problem # 1- 5/16/Schizophrenia
Problem # 2- 5/16/11 Med( medication) noncompliance
Problem # 3- 5/16/11-Auditory hallucinations
Problem/ Physical:
Problem # 4-Hypertension
The patient and registered nurse signed the form 5/16/11. The physician, counselor, activity/recreational director and social worker signed the form 5/24/11; 8 days after admission.

Written interview questions were presented to Employee Identified (EI) # 1 the Chief Nursing Officer on 7/13/11 at 3:30 PM regarding the treatment plan missing signatures, being completed 8 days after admission. On 7/14/11 at 10:50 AM, EI # 1 stated that the nurse manager was not aware of the 72 hours time frame for completion of the treatment plan.

Based on review of medical records, observation and interview it was determined the facility failed to document discharge summaries in an accurate manner. This had the potential to affect all patients served by this facility and did affect Patient Identifier (PI) # 29.

Findings include:

1. PI # 29 was admitted to PPS (Prospective Payment System) excluded Geriatric Psychiatric unit 4/29/11 with an Axis I diagnosis of Mood disorder, not otherwise specified and vascular cognitive impairment.

On 5/13/11 the patient was discharged to a medical bed in the hospital. A handwritten note form a registered nurse was added to a miscellaneous note documented an episode of low blood sugar and transfer to the medical floor.

The discharge summary from the physician dictated 6/1/11 documented the patient disposition, " The patient was discharged to the nursing home with instruction to take medications as prescribed and keep all follow up appointments.

The patient was actually discharged from the hospital 5/16/11.

Written interview questions were presented to Employee Identified (EI) # 1 the Chief Nursing Officer on 7/13/11 at 3:30 PM regarding the discharge summary and the patient still being in the hospital. On 7/14/11 at 10:50 AM, EI # 1, explained that it looked like the floor staff forgot to send the patient back to the unit prior to discharge.