HospitalInspections.org

Based on clinical record review, policy review and review of the bylaws the facility failed to ensure that a history and physical (H&P) for one recent admission (#48) was completed. The finding includes the following:

a. Patient #48 was admitted to the facility on 4/16/12. Review of the clinical record indicated that the physician attempted to complete the H&P on 4/17/12 however it was "deferred due to sedation". The H&P form dated 5/25/12 indicated that a second attempt was made to complete the physical, however, the patient refused. As of 7/12/12 Patient #48 had not had a physical completed.

Review of the H&P policy directed that an H&P should be completed within twenty-four hours of admission. The policy indicated that nursing and attending psychiatrist have daily interaction with the patient and are responsible for discerning when another attempt to complete the H&P should be made. Review of the Medical staff rules and regulations identified that if a patient refuses a H&P, the patient should be approached monthly.

Based on observation, clinical record review, and policy review, the hospital failed to ensure that the contracted service for hemodialysis was provided in accordance with physician orders and/or implemented infection control practices. The findings include the following:

Patient #29 had a history of end stage renal disease (ESRD) requiring hemodialysis three times a week, diabetes, bilateral above the knee amputations, Hepatitis C positive and MRSA. On 7/9/12, the patient was observed in the dialysis unit. Review of the physicians orders dated 6/22/12 directed treatment three days a week for four hours and Heparin 2,000 unit bolus at the start of treatment and 1,000 units mid treatment.

a. Review of the dialysis flow sheet dated 6/29/12 failed to identify that the mid treatment dose of Heparin had been administered.

b. RN #12 was observed on 7/9/12 during the period of 10:55 AM through 11:20 AM to touch the front of the dialysis machine and/or tubing in use by Patient #29 on three occasions without the benefit of wearing gloves. RN #12 then proceeded to other tasks in the unit without the benefit of hand hygiene.

Review of the Davita hand washing policy indicated that staff should wash hands before and after contact with a patient and/or patient delivery system.

Based on a review of clinical records, policy review, and interviews, for two patients reviewed for hydration (#30 and 105), the facility failed to provide sufficient fluid to maintain proper hydration and/or for two of three patients with altered nutrition (#47 and 105), the facility failed to ensure that physician orders for supplements were implemented and/or that weights were monitored in accordance with the MD order and/or for one patient reviewed with pressure ulcers (#47), the facility failed to ensure that wounds were monitored per facility policy and/or for 6 of 21 patient's (Patients #36, 29, 39, 28, 47 and 105), the facility failed to ensure treatment plans were individualized to meet the needs of the patient's.

Refer to A 395 and A 396.

Based on a review of clinical records, interviews and review of facility policy for two patients reviewed for hydration (#30 and 105), the facility failed to provide sufficient fluid to maintain proper hydration and/or for two of three patients with altered nutrition (#47 and 105), the facility failed to ensure that physician orders for supplements were implemented and/or that weights were monitored in accordance with the MD order and/or for one patient reviewed with pressure ulcers (#47), the facility failed to ensure that wounds were monitored per facility policy and/or for two of two patients (P #51 and P#42), the facility failed to assess an active medical condition, and/or conduct an accurate mental status assessment, and/or for one sampled patient (P #44), the facility failed to complete an annual fall assessment, and/or provide an intervention to prevent an injury, and/or document an assessment of the injury in the medical record and/or the facility failed to implement a consistent and/or comprehensive allowable item/suicide risk policy. The findings include:

a. Patient #30 was admitted on 4/23/12 with diagnoses that included schizoaffective disorder with a history of numerous suicide attempts resulting in triple limb amputations. Review of the progress notes identified that the patient was inpatient in an acute care facility from 6/20/12-6/22/12 with hypernatremia.


Review of the I&O record during the period of 6/23/12-6/26/12 identified that the patient's consumed fluids "occ" (for occasional), and/or zero, with zero fluid intake on 6/25/12, and 1430 cc intake on 6/26/12. The total 24-hour I&O was not calculated for any of those days.

The progress notes indicated that the patient was moved from Merrit Hall to Batell on 6/26/12.

Review of the I&O record identfied that the patient consumed 960 cc's of fluid on 6/27/12 and 240 cc's on 6/28/12. No urinary output was documented. The total 24-hour I&O was not calculated for those days.


A physician's order dated 6/29/12 directed to encourage electrolyte drinks and encourage oral intake. Review of the progress notes dated 6/27/12 through 7/9/12 identified repeatedly that Patient #30 was refusing food and fluids. The order dated 7/2/12 directed intake and output (I&O) for seven days and the order dated 7/6/12 directed to monitor I&O.

Review of the treatment plan dated 7/3/12 identified a problem for refusal of food and fluids with interventions that included in part, APRN to monitor patient's state of hydration and nutrition, follow input, vitals signs, labwork as indicated, collaborate with RNs and psychiatrist around issues of care in order to maintain adequate hydration and nutrition status. Nursing is responsible to monitor I&O every shift, offer fluids hourly, monitor vital signs every shift, electrolytes per MD order, and monitor for mental status changes. A "please monitor me for s/s of dehydration", document was located in the record that explained symptoms of mild, moderate, and severe dehydration with guidance for dehydration treatment.


Review of the I&O records during the period of 6/29/12 through 7/11/12, identified documentation that included, refused, occ (for occasional), and/or zero. The patient's fluid intake and/or urinary output was not calculated for the twenty-four hour periods as indicated on the I&O record to determine if the patient's fluid needs were met. The clinical record lacked evidence that dehydration assessments were conducted when the patient's I&O was insufficient.


Interview with staff on 7/10/12 at 2:30 PM indicated that the patient had refused all fluids and food since arrival to the floor on 6/27/12. The record reflected that the patient had been refusing vital signs, blood draws, food and fluid. On 7/11/12 the patient was sent to the ED for evaluation and was admitted for dehydration and remained hospitalized as of 7/12/12.


b. Patient #105 was admitted to the facility on 5/1/12 with diagnoses that included depression and suicidal ideation. A physician's order dated 5/1/12 directed a regular diet.

The Registered Dietician's (RD) note dated 5/2/12 identified that the patient was underweight by body mass index (BMI), weighted 120 lbs with an ideal body weight of 170 lbs. and required 2400 calories per day. The patient was noted to have poor fluid and food intake secondary to depression. The Dietician recommended a tender diet with soft fruits, vegetables, yogurt, supplements and to monitor oral intake for seven days. A physicians order dated 5/2/12 agreed with the RD's recommendations.

Review of the treatment plans dated 5/21/12, 5/25/12, 5/29/12, 6/4/12, and 6/18/12 failed to identify that the patient was underweight, was at risk for weight loss and/or dehydration.


A physician's order dated 5/29/12 directed "diet" and Glucerna, one can with meals if meals refused, and electrolyte replacement drink with meals. Review of the clinical record and interview with the Director of Psychiatry on 7/11/12 at 11:00 AM stated this order was not transcribed and/or that a specific diet was designated for the patient. The order dated 5/30/12 directed I&O monitoring for seven days, and an order dated 6/4/12, directed weekly weights.


The clinical record indicated that on 6/7/12 the patients weight was 124. The next documented weight on 6/28/12 identified that patient weighed 121, a three pound weight loss. The facility failed to ensure that weekly weights were obtained.


Additionally, review of the I&O sheets for the period of 5/2/12 through 7/11/12 (64 days) identfied that on 56 days the patient had a fluid intake of 500 cc's or less documented. Based on the patient's weight of 120 pounds on 5/1/12, the patient required 1,636 cc's of fluid daily to maintain hydration. The facility failed to ensure that I&O was consistently monitored as ordered and/or that the patient was assessed for signs and symptoms of dehydration when suboptimal intake was documented.



c. Patient #47 had diagnoses that included schizoaffective disorder and polysubstance abuse. Review of the clinical record indicated that the patient had a history of skin breakdown, was wheelchair bound and a Hoyer assist for transfers. Review of the ITP dated 6/29/12 identified an active problem for weight loss with interventions that included Glucerna 1.5 as needed if the patient consumes less then 50% of the meal and one at snack time, however the record failed to reflect an order for this, educate patient on food choices, weigh per MD orders, and inform MD and/or RD of concerns.


Review of the clinical record dated 5/2/12 reflected that a 2 cm by 2 cm pressure ulcer was observed on the sacrum, however, the assessment failed to identify staging of the wound. On 5/7/12, the wound was measured as 2 cm by 0.8 cm by 0.01 cm, absent of the staging. A new treatment order that directed to clean the coccyx open areas with normal saline, apply an aquacell dressing and change every 48 hours was obtained.

Review of the clinical record with the Director of General Psychiatry identfied that on 5/12/12, the coccyx/sacral wound was measured as 2 cm by 2 cm. The record failed to identify that the patient's pressure ulcer wound was next measured until 6/5/12 although the policy directs wound measurements weekly. The 6/5/12 assessment reflected that a new pressure ulcer had developed on the patient's left buttock (wound 1) that measured 3 cm by 2 cm and the existing pressure ulcer on the coccyx/sacrum (wound 2) was 2 cm by 2 cm.

The subsequent assessment dated 6/29/12, three weeks later, reflected that the buttock pressure ulcer (wound 1) had increased in size, measuring 3 cm by 2 cm by 0.25 cm and the sacral/coccyx pressure ulcer (wound 2) had also increased in size measuring 2 cm by 2 cm by 0.25 cm. The facility failed to ensure that weekly pressure ulcer wound assessments had been completed in accordance with facility policy.


Review of the Wound care policy directed that wounds would be measured (length, width and depth) weekly on Wednesdays. The policy indicated that wounds will be staged upon initial assessment.


d. Patient #47's record indicated that in December of 2011, the Patient experienced a significant weight loss over a six week period. The patient's weight in January 2012 was 189 with an ideal body weight of 144-183. A physicians order dated 5/24/12 directed a puree diet with Enlive 3-4 times a day. A nutrition consult dated 5/30/12 identfied recommendations that included add milk, yogurt, and cottage cheese to diet and Glucerna supplements. An order dated 6/21/12 directed a chopped diet with Enlive (supplement).


Review of the ITP dated 6/29/12 identified an active problem for weight loss/variable appetite with interventions that included in part, offer supplements as ordered, educate patient on healthy choices monitor meal intake and weigh weekly per physicians order.


The record failed to reflect that the patient was weighed during the periods of 6/3/12 through 7/8/12 and/or that recommendations from the 5/30/12 RD consult were reviewed with the physician. The record lacked evidence that the RD had evaluated the patient since 5/30/12 despite the patient being at risk for weight loss.

Subsequent to surveyor inquiry, Patient #47 was weighed on 7/11/12 with a weight of 167 pounds, a twenty-two (22) pound weight loss since January.

Interview with the Supervising Dietician on 7/12/12 at approximately 11:45 AM indicated she reviewed Patient #47's record and was unsure why the recommendations had not been implemented. The Supervising Dietician stated that all patients are seen annually, moderate risk patients are seen every six months, and high risk patients are seen quarterly. The Supervising Dietician stated that patient risk level is assessed at each visit and that Patient #47 was high risk. However review of the RD notes and/or assessments with the Director of Psychiatry failed to identify the risk level assigned.


e. Patient #51 was admitted to the hospital on 7/7/12 for detoxification and rehabilitation due to alcohol use. Patient #51 ' s diagnosis included alcohol dependence, depressive disorder and severe peripheral vascular disease. Review of the clinical record identified Patient #51 was scheduled for vascular surgery in approximately two weeks. Interview and review of the clinical record with the Director of Nursing on 7/11/12 at 11:00 AM identified nursing failed to complete an initial and/or ongoing peripheral vascular assessment for Patient #51. Review of the hospital policy for Integrated Treatment Planning Process directed, in part that all patients admitted for care are assessed by a registered nurse who identified the individual ' s psychiatric, behavioral, and medical treatment needs. Further review of the policy directed after interdisciplinary assessments are completed the formulation of the Integrated Treatment Plan is developed.
f. Patient # 42 was admitted to the hospital on 5/22/12 from the court for competency restoration. Patient #42 ' s diagnosis included obsessive compulsive disorder, psychotic symptoms and substance abuse. On 7/2/12 at 5:00 PM while Patient #42 was on a fresh air break he/she became agitated and attempted to charge after a nurse. Patient #42 was placed in a physical hold, was administered medications to reduce agitation and was placed on constant observation. Review of the clinical record with Nurse Manager #2 on 7/10/12 at 1:00 PM identified a mental status examination was completed on 7/2/12 at 5:00 PM that identified Patient #42 was appropriate, and cooperative. Nurse Manager #2 indicated the mental status examination was documented inaccurately and should have reflected the behavior that was identified at 5:00 PM.
g. P #44 was admitted to the hospital on 8/31/95 and remained committed to the jurisdiction of the Psychiatric Security Review Board. Patient #44 ' s diagnosis included psychotic disorder, antisocial, borderline and narcissistic personality disorder. Review of the clinical record identified on 1/29/12 Patient #44 attempted to " spit " at staff, lost his balance and fell. Patient #44 was transferred to an acute care setting for medical treatment. On return to the facility Patient #44 was placed on constant observation for risk of assault, water intoxication and harm to self. On 2/6/12 Patient #44 ' s observation status was increased to a two to one observational level due to risk of falls secondary to a shuffling gait, refusal to wear appropriate footwear and combative, impulsive behaviors. Interview and review of the clinical record with the Director of Forensics on 7/9/12 at 12:00 PM identified although a post fall assessment was completed on 1/29/12 the facility failed to complete an annual fall risk assessment per hospital policy. The hospital policy for Assessment of Fall Risk and Falls directed a fall risk assessment to be completed on admission, annually and with a change in physical condition.
Review of the clinical record and facility documentation identified on 7/8/12 at 5:00 PM Patient #44 was in seclusion and sustained a three centimeter abrasion on the forehead from banging his/her head on the door. Further review of the clinical record identified at 5:15 PM Patient #44 continued to bang his/her head. Interview with Nurse Manager #1 on 7/9/12 at 1:15 PM identified a nursing intervention should have been implemented at 5:00 PM to prevent further potential injury to Patient #44.
Interview, review of the clinical record and facility documentation with the Director of Forensics on 7/9/12 at 12:10 PM identified that although the physician documented the medical assessment of Patient #44 on the facility incident report dated 7/8/12, the injury was not documented in the clinical record and failed to direct the medical care of the patient following the injury. Subsequent to the surveyors inquiry on 7/9/12 the physician documented a medical progress note regarding the injury.
Review of the hospital policy with the Nurse Executive on 7/12/12 at 11:00 AM for allowable items failed to identify a comprehensive, consistent allowable items list for each individual unit. The evaluation and management of the suicide risk policy failed to direct safety interventions that would be implemented on individual units in the event that a patient was suicidal.

1. Based on a review of clinical records, interview and review of policy, the facility failed to ensure that 9 of 21 patient's (Patients #36, 29, 39, 28, 42, 47, 51, 52 and 105) had comprehensive and/or individualized treatment plans to meet the needs of the patient and/or that the plans were reviewed. The findings include the following:


a. Review of Patient #36's clinical record indicated that the patient had been admitted to the facility on 8/19/11 with bipolar and schizoaffective disorders. The clinical record indicated that the patient was transferred to Woodward 2 north on 7/6/12. The clinical record indicated that since the move the patient had been experiencing an increase in agitation. Review of the treatment plan completed 6/26/12 failed to address the patient's transfer/move.


b. Patient #29 has diagnoses that included end stage renal disease (ESRD) requiring hemo dialysis three times a week, diabetes, bilateral above the knee amputations, MRSA and required non-invasive ventilation (CPAP). Review of the treatment plans dated 5/9/12 and 7/2/12 failed to reflect that the patients need for hemodialysis and non invasive ventilation had been addressed.


c. Patient #39 was admitted with diagnoses including schizoaffective disorder and borderline personality. The clinical record indicated that the patient had fallen on 6/19/12 and 6/24/12. The monthly treatment plan completed on 6/24/12 indicated that the patient was a fall risk with interventions that included reevaluate patient for change of condition, notify MD and PT as needed, assist with ADL's, and monitor for gait changes. On 7/2/12, the patient fell resulting in right arm pain. The monthly treatment plan dated 7/6/12 identified the patient was a fall risk with the same interventions identified. The ITP failed reflect that the plan had been reviewed subsequent to the falls the patient experienced in June and July.


d. Patient #28 had a history of violent, aggressive behaviors and had been receiving electroconvulsant therapy (ECT) with positive results. The record indicated the patient had an eight month period with no episodes of aggressive behaviors with ECT stopped approximately one month ago due to the discovery the patient had multiple questionable area's in his/her lung that required medical evaluation. The record identified that the patient was involved in eight episodes of aggressive behaviors requiring staff intervention resulting in patient and/or staff injuries. Review of the ITP dated 6/6/12 identified the objective that the patient will continue to manage impulses to attack and/or hit others. The focused ITP's dated 6/11/12 and 6/22/12 identified the same problems/objectives however the focused ITP failed to reflect additional interventions, plans and/or services to assist the patient to achieve the identified objective. The ITP failed to identify the reason for the focused review as well.

In addition under the patients active medical problems Rhinitis, acid reflux and hypercholesterolemia were the only problems identified. The ITP failed to address the patients lung masses and/or the cessation of ECT as a result.


e. Patient #47 had diagnoses that included schizoaffective disorder and polysubstance abuse. The clinical record indicated that in December of 2011, the Patient experienced a significant weight loss over a six week period. The clinical record identfied that the patient's weight in January 2012 was 189. A physician's order dated 5/24/12 directed a puree diet with Enlive 3-4 times a day. A nutrition consult dated 5/30/12 identfied recommendations to add milk, yogurt, cottage cheese to the trays, and Glucerna supplements. An order dated 6/21/12 directed a chopped diet with Enlive (supplement). Although the ITP dated 6/29/12 identified an active problem for weight loss that identified the patient was on Glucerna 1.5 as needed if patient consumes less then 50% of meal and one at snack time. The record failed to reflect an order for the Glucerna rendering the plan inaccurate. Additional intervention's noted on the plan included educate patient on food choices, weigh per MD orders (weekly), and inform MD and/or dietician of concerns. The facility failed to ensure that the ITP was accurate and/or individualized to meet the needs of the patient. Subsequent to surveyor inquiry, the patient's weight was obtained on 7/11/12 and documented as 167 pounds, a 22 pound weight loss since January.


f. Patient #105 was admitted to the facility on 5/1/12 with diagnoses that included depression and suicidal ideation. A physician's order dated 5/1/12 directed a regular diet. The RD's note dated 5/2/12 identified that the patient was underweight by body mass index (BMI), weighed 120 lbs with an ideal body weight of 170 lbs. and required 2400 calories per day. The patient was noted to have poor fluid and food intake secondary to depression. The Dietician recommended a tender diet with soft fruits, vegetables, yogurt, supplements and to monitor oral intake for seven days. A physicians order dated 5/2/12 agreed with the RD recommendations.

Review of the treatment plans dated 5/21/12, 5/25/12, 5/29/12, 6/4/12, and 6/18/12 failed to identify that an individualized plan of care was developed to address the patient's risk for weight loss and/or dehydration.


The clinical record indicated that on 6/7/12 the patients weight was 124. The next documented weight on 6/28/12 identified that patient weighed 121, a three pound weight loss.


Review of the I&O sheets for the period of 5/2/12 through 7/11/12 (64 days) identfied that on 56 days the patient had a fluid intake of 500 cc's or less documented. Based on the patient's weight of 120 pounds on 5/1/12, the patient required 1,636 cc's of fluid daily to maintain hydration. The facility failed to ensure that I&O was consistently monitored as ordered and/or that the patient was assessed for signs and symptoms of dehydration when suboptimal intake was documented.


Review of the facility policy "Integrated Treatment Planning Process" identified a focused treatment plan should be completed when there is a change in condition and the plan should be focused on alterations necessitated by the change in condition. Review of the Nutritional Assessment policy indicated that a comprehensive risk assessment is performed by a dietician on all admissions. The policy identified that the Dieticians will ensure that pertinent nutritional information from the assessment will be integrated into the treatment plan.

g. Patient #51 was admitted to the hospital on 7/7/12 for detoxification and rehabilitation from alcohol. Patient #51 ' s diagnosis included alcohol dependence, depressive disorder and severe peripheral vascular disease. Review of the clinical record identified Patient #51 was scheduled for vascular surgery in approximately two weeks. Interview and review of the clinical record with the Director of Nursing on 7/11/12 at 11:00 AM indicated the treatment plan failed to identify peripheral vascular disease as an active problem with interventions that were individualized for Patient #51.
h. Patient #52 was admitted to the hospital on 6/26/12 for detoxification and rehabilitation from alcohol dependence. Patient #52 ' s diagnosis included alcohol abuse and schizoaffective disorder. Interview and review of the clinical record with the Director of Nursing on 7/11/12 at 11:15 AM indicated the treatment plan failed to identify schizoaffective disorder as an active problem with interventions that were individualized for Patient #52.
i. Patient # 42 was admitted to the hospital on 5/22/12 from the court for competency restoration. Patient #42 ' s diagnosis included obsessive compulsive disorder, psychotic symptoms and substance abuse. Interview and review of the clinical record with Nurse Manager #2 on 7/10/12 at 1:15 PM identified when Patient #42 interacted with family members he/she was agitated and demonstrated hostile behaviors intermittently requiring immediate interventions to prevent imminent risk to others. Further review of the clinical record failed to identify a plan of care with interventions that were individualized for Patient #42 when contact with family members occurred. Review of the hospital policy for Integrated Treatment Planning Process directed in part the identification of psychiatric, behavioral and medical issues and to initiate appropriate treatment and follow up care. The policy further directed the plan of care would list the frequency and focus of interactions which provided nursing with clear and concise psychiatric and medical treatment interventions required by the individual in recovery.

Based on a review of clinical records, interviews and review of facility policy, the facility failed to ensure that the Registered Dietician performed risk assessments for 2 of 2 patient's (#47 and #105) and/or reevaluated the patient's subsequent to recommendations to determine if the interventions were implemented and/or effective. The findings include the following:


a. Patient #47 had diagnoses that included schizoaffective disorder and polysubstance abuse. Review of the clinical record indicated that the patient had a history of skin breakdown, was wheelchair bound and a Hoyer assist for transfers. The record indicated that in December of 2011, the Patient experienced a significant weight loss over a six week period. The patient's weight in January 2012 was 189 with an ideal body weight of 144-183. A physicians order dated 5/24/12 directed a puree diet with Enlive 3-4 times a day. A nutrition consult dated 5/30/12 identfied recommendations that included add milk, yogurt, and cottage cheese to trays and Glucerna supplements. An order dated 6/21/12 directed a chopped diet with Enlive (supplement). Review of the ITP dated 6/29/12 identified an active problem for weight loss with interventions that included Glucerna 1.5 as needed if the patient consumes less then 50% of the meal and one at snack time, however the record failed to reflect an order for this. Additional interventions included educate patient on food choices, weekly weights per MD order, and inform MD and/or RD of concerns.


The record failed to reflect that the patient was weighed during the periods of 6/3/12 through 7/8/12 and/or that recommendations from the RD consult dated 5/30/12 were reviewed with the physician.


Subsequent to surveyor inquiry, Patient #47 was weighed on 7/11/12 with a weight of 167 pounds, a twenty-two (22) pound weight loss since January.

Interview with the Supervising Dietician on 7/12/12 at approximately 11:45 AM indicated she reviewed Patient #47's record and was unsure why the recommendations had not been implemented. The Supervising Dietician stated that all patients are seen annually, moderate risk patients are seen every six months and high risk patients are seen quarterly. The Supervising Dietician stated that patient risk level is assessed at each visit and that Patient #47 was high risk. However review of the dietician notes and/or assessments with the Director of Psychiatry failed to identify the risk level assigned.

The RD failed to reevaluate the patient subsequent to recommendations made on 5/30/12 for diet augmentation and/or collaborated with the interdisciplinary team regarding weekly weights per the plan of care to ensure the patient's nutritional needs were met.


b. Patient #105 was admitted to the facility on 5/1/12 with diagnoses that included depression and suicidal ideation. A physician's order dated 5/1/12 directed a regular diet. The RD's note dated 5/2/12 identified that the patient was underweight by body mass index (BMI), weighted 120 lbs with an ideal body weight of 170 lbs. and required 2400 calories per day. The patient was noted to have poor fluid and food intake secondary to depression. The Dietician recommended a tender diet with soft fruits, vegetables, yogurt, supplements and to monitor oral intake for seven days. A physicians order dated 5/2/12 agreed with the RD's recommendations.

Review of the treatment plans dated 5/21/12, 5/25/12, 5/29/12, 6/4/12, and 6/18/12 failed to identify that the patient was underweight, was at risk for weight loss and/or dehydration.


A physician's order dated 5/29/12 directed "diet" and Glucerna, one can with meals if meals refused, and electrolyte replacement drink with meals. Review of the clinical record and interview with the Director of Psychiatry on 7/11/12 at 11:00 AM stated this order was not transcribed and/or that a specific diet was designated for the patient. The order dated 5/30/12 directed I&O monitoring for seven days, and an order dated 6/4/12, directed weekly weights.


The clinical record indicated that on 6/7/12 the patients weight was 124. The next documented weight on 6/28/12 identified that patient weighed 121, a three pound weight loss. The facility failed to ensure that weekly weights were obtained.


Additionally, review of the I&O sheets for the period of 5/2/12 through 7/11/12 (64 days) identfied that on 56 days the patient had a fluid intake of 500 cc's or less documented. Based on the patient's weight of 120 pounds on 5/1/12, the patient required 1,636 cc's of fluid daily to maintain hydration. The facility failed to ensure that I&O was consistently monitored as ordered and/or that the patient was assessed for signs and symptoms of dehydration when suboptimal intake was documented.


Review of the dietician notes and/or assessments on 7/12/12 with the Director of Psychiatry failed to identify the risk level assigned. The RD failed to develop an individualized treatment plan that addressed concerns noted on 5/2/12 and/or reevaluated the patient subsequent to recommendations for diet changes and/or monitoring of fluid intake and/or weekly weights to ensure the patient's food/fluid needs were met.

Review of the Nutritional Assessment policy indicated that a comprehensive risk assessment is performed by a dietician on all admissions. Each patient will be reassessed at least annually or more frequently when a significant change occurs. The policy does not identify the frequency the risk levels and/or the frequency of review.

Based on observation and interview, the hospital failed to ensure that the environment was free from potential hazards. The findings include the following:

a. During tour of the Young Adult Services Unit with the DNS on 7/9/12, leather restraints tied to a bed were observed to have a torn and ragged lining (that would interface with patients skin) rendering it impossible to effectively cleanse the restraint between patients. The Director removed the restraint from the bed and requested a new restraint.

b. During tour on 7/9 and 7/10/12 of Merritt Hall, observation of the bathrooms located on each floor at the back of the building identified a wooden door held in place with three individual projecting hinges allowing a potential for hanging. During interview with the Directors of each unit on the above identified days failed to identify why the hinges of said door failed to match the hinges of other doors seen throughout the patient units.

c. During tour on 7/9 and 7/10/12 of Merritt Hall shower/bathing areas identified several bathtubs throughout the building that had a protruding waterspout without breakaway capability. During interview on 7/10/12, the Director of Engineering stated that the bathtubs were slated for removal, however, as of 7/9/12, the removal had not occurred.

d. During tour on 7/9/12 of Merritt Hall 3 E observation of the shower/bathroom area identified a vinyl shower seat that was supported with vinyl tubing, making it a safety risk. Although the seat set-up was different from the other unit showers, no one present during the tour, could answer as to why.

e. During tour on 7/10/12 of Merritt Hall 4B identified a shower chair, stored in the shower room, made completely of PVC tubing, making it a safety risk. During interview on 7/10/12, the DNS stated she was unsure why it would be stored in the shower room, since it was not a piece of equipment utilized by all patients.

Based on a review of the clinical record, review of hospital policies, and interviews for one sampled patient (Patient #52), the facility failed to include a discharge plan of care and/or services that were needed post hospitalization in the clinical record.
a. Patient #52 was admitted to the hospital on 6/26/12 for detoxification and rehabilitation from alcohol dependence. Patient #52 diagnosis included alcohol abuse and schizoaffective disorder. Interview and review of the clinical record on 7/11/12 at 11:30 AM with the Director of Nursing identified that, although weekly social work documentation was reflected in the clinical record, the progress note failed to identify the patients current discharge plan including housing, outpatient and support services, vocational, day treatment and finances. Subsequent to the surveyors inquiry a progress note that included a specific plan of care for hospitalization and post hospitalization was addressed in the progress note by the social worker. The hospital policy for discharge planning directed in part that ongoing assessments of discharge planning should reflect the patient ' s and others ' involvement in the discharge planning process. It should also reflect progress towards discharge, barriers to discharge, and/or issues that require ongoing treatment in a hospital setting, or recommendations to move the patient to a less restricted setting within the hospital or in the community. The policy further directed that weekly social work progress notes are required for the first eight weeks of hospitalization. Each Social Work Progress note must document discharge planning, addressing needs relating to housing, support services, vocational, day treatment, and finances.

Based on clinical record review and review of the facility policy the facility failed to ensure that continuous positive airway pressure (CPAP) ventilation was administered based on a comprehensive order. The finding includes the following:

a. Review of the clinical record for Patient #29 identified a physicians order dated 6/19/12 for CPAP 10/5 with 2 liters of oxygen at bedtime. The order for CPAP directed variable airway pressures and failed to identify mode (timed or spontaneous) and/or the backup rate.

Review of the CPAP policy indicated that the order for CPAP should include pressure. The policy failed to reflect the different order requirements for BiPAP versus CPAP.

Based on observations, interviews and record review, the facility failed to provide active treatment for active sample patients and additionally failed to provide for timely discharge for active sample forensic patients. These failures place at patients at risk for not being able to receive care in a timely manner and may delay the patient's opportunity to recover.

More specifically:

I. Based on record review, observation and interview, the facility failed to provide active psychiatric treatment, including alternative interventions, for 1 of 1 active sample patient (#100) on the Traumatic Brain Injury Unit, and 1 of 3 active sample patients (#102) on the Geriatric Unit, who were either not cognitively capable of participating in treatment and/or were not motivated to attend their assigned treatment groups. Failure to provide active treatment for patients results in the patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement. (Refer to B125-I)

II. Based on observation, interview and record review, the facility failed to provide individualized treatment based on the presenting needs of 1 of 18 active sample patients (#105). This patient failed to attend most of the modalities listed on the treatment plan, and was observed to be in bed during the times group treatments were taking place. Although interview and record review revealed that staff was aware that the patient was not utilizing the modalities listed on the treatment plan, the staff did not develop alternative treatment modalities to meet this patient ' s needs. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided. This potentially delays their improvement. (Refer to B125-II)

III. Based on record review and interviews, the facility failed to discharge to a less restrictive level of care, 3 of 4 forensic active sample patients (#109, 110 and 111) two of whom, despite significant cognitive impairments (#109 and 111), had reached stability in psychiatric symptoms and no longer required acute hospital care, and the third (#110) who lacked documented need for inpatient psychiatric treatment. These patients were retained due to circumstances unrelated to their psychiatric needs. The medical record documentation for patients #109 and #111 failed to demonstrate that inpatient services were of an intensity and frequency to justify the more restrictive level of care. Documentations for Patient #109, who had developmental disabilities, also revealed concerns about managing his/her safety on a unit that served forensic patients who could and did threaten his/her safety. These failed practices impinge on patients' rights to be treated in the least restrictive setting appropriate to their needs and absorbs staff time which should be directed to the acute patients. (Refer to B125-III)

IV. Based on record review and interview, the facility failed to ensure that discharge summaries contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 7 of 8 discharged patients whose records were reviewed (#118, 120, 121, 122, 123, 124 and 125). Additionally, the physician dictation for two patient records (#119 and #120) was completed after the scheduled outpatient appointment follow up date. This results in a lack of critical clinical information, indicating the patient's level of psychiatric symptomatology and risk, being available to aftercare providers. (Refer to B134)

Based on record review, observation and interview, the facility failed to provide active psychiatric treatment, including alternative interventions, for 1 of 1 active sample patient (#100) on the Traumatic Brain Injury Unit, and 1 of 3 active sample patients (#102) on the Geriatric Unit, who were either not cognitively capable of participating in treatment and/or were not motivated to attend their assigned treatment groups. Failure to provide active treatment for patients results in the patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement.

Findings include:

Specific Patient Findings

Patient #100

Patient #100 was admitted on 8/20/10. The annual Psychiatric Evaluation, dated 8/20/11, stated that the diagnosis was "Vascular Dementia." "Barriers to achieving discharge goals are that [name of patient] has some very serious cognitive impairments which have not been adequately addressed and treated. Further dementia may prove to be a barrier if its deteriorating course interferes with success of focused neurological rehabilitation."

A. Observation

Patient #100 was observed sitting in a wheelchair in a hallway on unit B2 South on 6/9/12 at 11:40 a.m. When approached after an introduction, the patient just smiled and said nothing. No staff member was observed trying to communicate with the patient between 11:40 a.m. and 2 p.m. at which time the Rehab group leader was observed inviting the patient to a "Vocational Rehabilitation - Clerical group" starting on the unit. A group of 4 patients, including patient #100 sat at a table putting letters in envelopes. Patient #100's job was to seal each envelope with a small piece of scotch tape. Even though the group leader frequently encouraged patient #100 about performing the task, the patient did not respond verbally, and- just sat quietly taping each envelope shut with the tape.

Record Review

1. Patient #100's Master Treatment Plan (MTP), last updated 7/2/12, stated "[name of patient] has sustained a series of brain injuries, including a traumatic brain injury at age 6 from a bike accident and substance abuse injuries leading to DTs [delirium tremens], seizures and ultimately anoxic damage. [Patient] has had acute cognitive and physical impairments since heroin overdose in 2002 and was maintained in a skilled nursing facility prior to developing aggressive and disorganized behavior which necessitated transfer to [present facility]." "Based on lifetime history of a series of brain injuries and current non-fluent aphasia with total ADL [activities of daily living] care needs, the diagnosis of dementia secondary to cerebral anoxia appears to best summarize [his/her] current diagnostic state."

An objective in the MTP was "[Name of patient] will demonstrate non-assaultive behavior for 60 days as documented in progress and nursing notes." The listed interventions included: "sensory enhancement - five stage group 2 times per week" - by COTA [Certified Occupational Therapy Assistant] and "medication management weekly" by MD [doctor].

2. A review of Patient #100's "Core Group activity schedule," updated 6/25/12, listed five therapeutic groups [usually 45 minutes in length] assigned to the patient. They were: Mondays - "VOC rehab [vocational rehabilitation] - Clerical" - 2:00 p.m.; Tuesdays - no group assignment; Wednesdays - "VOC rehab - Radio" at 9:30 a.m. and "OT [occupational therapy] Enhancement" - at 1:15 p.m.; Thursdays - "Men's Group" - Social work hallway group room at 2:15 p.m.; and Fridays - "OT Sensory Enhancement" at 1:15 p.m.

3. A review of the patient's attendance at groups for the period of 6/11/12 to 7/9/12 (13 work days) showed that Patient #100 was scheduled for approximately 25 hours of the five therapeutic groups listed on the core schedule above, but attended a total of two of the groups ["Vocational Rehab - Clerical" and "medication group"] for a total 6.75 hours. No alternative interventions were included on the MTP when patient #100 refused to attend scheduled groups.

C. Interviews

1. In an interview on 7/10/12 at 2:10 p.m., the lack of consistent group attendance by patient #100 was discussed with RN50. RN50 was asked about what staff does when the patient refuses to go to assigned groups. RN50 replied, "Nothing. They just leave the patient alone." When asked what patient #100 did on the unit during the times assigned groups were scheduled for the patient and the patient refused to go, RN50 stated, "[patient] likes to watch TV."

2. In an interview on 7/11/12 at 10:00 a.m., the lack of consistent scheduled group attendance of patient #100 was discussed with MD50. When MD50 was told that the patient often refused to attend groups, MD 50 stated, "That's not terribly surprising to me. Some patients have credible limitations."

3. In an interview on 7/11/12 at 10:20 a.m., RN50 was asked what type of interactions MHAs [Mental Health Assistants] have with patient #100 on the unit when the patient has long idle times due to so few scheduled groups, along with refusal to go to groups that are scheduled. RN50 stated that MHAs are only assigned to patients to assist with ADLs (i.e. toileting, eating, etc.) as needed.

Patient #102

Patient #102 was admitted on 12/5/02. The last annual Psychiatric Evaluation, dated 11/30/11, stated that the diagnosis was "Alcohol Related Dementia." The psychiatric Evaluation stated, "[Name of patient] has continued to be explosive and verbally threatening at times, but has generally been clinically stable. [Patient] has been able to carry on a logical and appropriate conversation with staff, and at times has appeared to be without severe dysfunction. However [patient's] substantial dementia has continued to cause serious cognitive impairment and disinhibition that led to serious problematical behaviors and general behavioral dyscontrol for a long time now." "[Patient] has continued to be threatening and agitated, threatening to hit staff, and often swearing at staff when additional food is not immediately given to him" and "[Patient] often insists on more food even right after a meal, forgetting that [s/he] has just eaten." "[Patient] also continues to make frequent and sexually inappropriate remarks to female staff and sometimes grabs and touches staff inappropriately. "

A. Observation

An attempt was made to observe patient #102 in the scheduled "Guided Relaxation Group" on 7/9/12 at 2 p.m. However, patient #102 was observed lying in bed in room 226 with back facing the door. When RN51 was asked why patient #102 was in bed, not in group, RN52 stated "[Patient] likes to sleep and eat."

B. Record Review

1. Patient #102's MTP, last updated 6/26/12, had an objective of "[name of patient] will manage and reduce [his/her] sexually inappropriate ... and threatening statements [e.g. 'I am going to come over there and pound you in the head'] as evidenced by utilizing coping strategies [e.g. deep breathing, removing self from the room, accepting redirection] during interactions with patients and staff on unit and during groups for a minimum of 30 minutes daily for the next consecutive 30 days." The listed group interventions included: "Sensory Stimulation" 30 minutes 2 times per week by BA (Bachelor's) clinical staff, "Guided Relaxation" 30 minutes 2 times per week by Psychologist, "Medication Management" 10 minutes monthly by MD.

For the objective - "[Patient] will maintain his current level of cognitive and physical functioning as evidenced by practicing cognitive and physical tasks in- on and off- unit groups a minimum of twice weekly for the next consecutive 30 days," the listed group interventions were: "Cognitive Stimulation" 30 minutes 2 times per week by Psychologist, "Reminiscing Group" 20 minutes 2 times per week by social worker and an "Orientation [Reality] Exercise" 15 minutes 5 times per week by nursing staff.

2. A review of Patient #102's activity schedule showed that the patient was scheduled for 5 groups daily Monday through Friday between 8:30 a.m. and 3 p.m. (With the exception that on Fridays 3 times per month, only 4 groups were scheduled). The groups were as follows: "Orientation Group" from 8:30 a.m. to 8:45 a.m. 5 days per week; "Community Meeting" from 8:45 a.m. to 9 a.m. 5 days per week; "Reminiscence Group" from 9:15 a.m. to 10 a.m. Monday and Wednesday; "Cognitive Stimulation" at the same time Tuesday and Thursday; "Dance Therapy" Monday and Wednesday from 10:15 a.m. to 11 a.m.; "Music Therapy" Tuesday and Thursday at the same time; and "Women's Group" on Fridays 3 times per month; "Sensory Stimulation and ADL Group" Tuesday and Thursday from 1 p.m. to 1:50 p.m.; "Socialization Group" on Fridays from 1 p.m. to 1:50 p.m. and from 2:30 p.m. to 3 p.m. and "Guided Relaxation" on Monday and Wednesday from 2:30 p.m. to 3 p.m. There were no formal groups held on the weekends. The number and frequency of the groups were not enough to result in improvement in the patient's condition.

3. A review of the patient's attendance at scheduled groups for the period of 7/2/12 and 7/10/12 (7weekdays) showed that patient #102 was scheduled to attend 20 groups during that time. Patient #102 attended a total of 8 of the 20 scheduled groups as follows: on 7/2/12 and 7/3/12 the patient attended 3 of 4 scheduled groups on each day. Groups not attended were: "Guided Relaxation" on 7/2/12 and "Sensory Stimulation" on 7/3/12. On 7/5/12 and 7/6/12, the patient did not attend any groups. Groups not attended were: "Orientation, AM Meeting, Cognitive Stimulation, and Socialization" on 7/5/12 and "Orientation, AM Meeting and Socialization Group" on 7/6/12. The day of 7/4/12 was not listed at all for group attendance. On 7/9/12 and 7/10/12, the patient did not attend any scheduled groups. Groups not attended were: "Orientation, AM Meeting, and Guided Relaxation" on 7/9/12 and "Orientation and Cognitive Stimulation" on 7/10/12.

C. Interviews

1. In an interview on 7/11/12 at 11:20 a.m., the failure of patient #102 to consistently attend scheduled groups was discussed with MD51. MD51 stated, "I'm not surprised. [Name of patient] is not psychotic; patient does suffer from memory impairment. What's keeping [him/her] in the hospital and from being discharged to a nursing home is that [patient] keeps [groping staff and patients]. A nursing home will not put up with that."

2. In an interview on 7/11/12 at 11:29 a.m., the problem of getting patient #102 to attend groups was discussed with RN52. RN52 was asked what nursing staff was doing to encourage the patient to go to groups. RN52 stated, "Staff is not concerned about the patient not going to groups. After breakfast and lunch [patient] goes to [his/her] room. We try to keep [patient] occupied, but patient will get aggressive if pushed too hard to go to groups."


Based on observations, interviews and record review, the facility failed to provide individualized treatment based on the presenting needs of 1 of 18 active sample patients (#105). This patient failed to attend most of the modalities listed on the treatment plan, and was observed to be in bed alone, during the times group treatments were taking place. Although interviews and record review revealed staff was aware that the patient was not utilizing the modalities designated on the treatment plan, the staff did not develop alternative treatment modalities to meet this patient's needs. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided. This potentially delays their improvement.

Findings include:

A. Observation:

On 7/10/12 at 2 p.m., Patient #105 was observed in the patient's room, lying in bed. S/he was dressed only in sweat pants. It was observed that that the pillow case had several stains. The patient had a dried, crusted substance around the mouth and his/her teeth were severely decayed. There was obvious body odor in the room. The patient remained in bed during the interview and stated, "I just want to die. The medications don't work. Groups don't help."

B. Record review:

Patient #105 was admitted to the hospital 5/1/12 (MTP updated 7/9/12)

1. The "Recovery Goal Description" states "Discharge/The client is a single Caucasian... sent...for active depression with suicidal ideation and plan. Patient Actions: The client will be an active participant into the treatment fold, attending treatment team meetings, groups and activities."

2. The patient was assigned to the following groups: " DBT-Distress Tolerance- twice weekly, Community Meeting- 5 times per week, Engagement Motivation -2 times per week, Wrap- 2 times per week. "

3. The "Psychiatry Weekly Note (5/5/12)" stated, "Participation and progress in Treatment ...Isolative, refusing to participate in milieu or groups. Remains suicidal risk. Wants IM [Intramuscular] medications only. At times asks for prescription of Cannabis."

4. The "Monthly Psychiatric Progress Note (6/4/12)" stated, "Remains very depressed, suicidal (highly) and withdrawn. Not eating well. Presents risk to others and [him/her] self."

5. A "Psych" [sic] MD note (7/2/12) said that the patient stated, "I need to sleep... you have to help me sleep. Staying in bed is comfortable thing for me. I am very suicidal but I just don't eat and die. That is how I feel." The note also said, "[S/he] continues to be isolative, needs encouragement. Not making any suicidal gestures except for intake."

6. The "Patient Consistency of Group Programming" for the period "6/28/12 through 7/11/12" stated that the patient was scheduled for 50 hours of assigned groups and attended 6 hours. The "Breakfast - Lunch - Dinner Log" for the period 7/3/12 through 7/11/12, stated that the patient stayed in his/her room during breakfast on 8 of 9 days, lunch 9 of 9 days, and dinner on 7/5, 7/4, 7/6, and 7/8. The remaining days were not documented.

7. The "Medication Administration Record (MAR)" stated that the patient refused Haldol Decanoate 50mg IM q [every] 2 weeks on 6/18 and 7/2 and Haldol 15mg po daily at (8 p.m.) on 7/1-11/12.

C. Interviews

1. In an interview in the unit conference room on 7/10/12 at 3 p.m., MD 53 stated that the patient had had Electroconvulsive Treatments (ECT) in another hospital before the patient was admitted to Connecticut Valley Hospital and that it had not been effective. MD 53 said, "Maybe we should be more aggressive in our treatment here" regarding court ordered medications. MD 53 acknowledged that the patient was not participating in treatment as prescribed in the treatment plan.

2. In an interview on 7/10/12 at 2 p.m., RN 53 acknowledged that the patient was eating and drinking very little, refused to shower and attend to other hygiene, refused medication, and was rarely leaving his/her room.


Based on record review and interviews, the facility failed to discharge to a less restrictive level of care, 3 of 4 forensic active sample patients (#109, 110 and 111) two of whom, despite significant cognitive impairments (#109 and 111), had reached stability in psychiatric symptoms and no longer required acute hospital care, and the third (#110) who lacked documented need for inpatient psychiatric treatment. These patients were retained due to circumstances unrelated to their psychiatric needs. The medical record documentation for patients #109 and #111 failed to demonstrate that inpatient services were of an intensity and frequency to justify the more restrictive level of care. Documentations for Patient #109, who had developmental disabilities, also revealed concerns about managing his/her safety on a unit that served forensic patients who could and did threaten his/her safety. These failed practices impinge on patients' rights to be treated in the least restrictive setting appropriate to their needs and absorbs staff time which should be directed to the acute patients. (Refer to B125-III)

Findings include:

A. Patient #109

1. Record/Document Review

a. According to the Integrated Psychiatric Assessment dated 4/16/12, Patient #109 was a young adult who was never previously hospitalized. The patient was transferred from a correctional institution where s/he had been incarcerated. The psychiatric assessment indicated some confusion regarding the patient's criminal obligations which resulted in a civil commitment to the hospital's forensic division. At the time of the completion of the Integrated Psychiatric Assessment, the patient's only ordered medication was a prn for "Lorazepam 1 mg po [orally] q [every] 12 hrs," a mild anti-anxiety medication. The assessment concluded with diagnoses of Axis I. R/O Reading Disorder, R/O [rule out] Attention Deficit/Hyperactivity Disorder; Cannabis Abuse; Nicotine Dependence; Axis II. Mental Retardation, Moderate; and Axis III. History of Seizures and Asthma. None of these diagnoses would require inpatient psychiatric treatment.

b. According to a "Psychiatric Transfer Note" dated 7/11/12, the patient was transferred to another unit in the same building (on 7/11/12) due to concerns about the patient's safety. Specifically, the patient reported that that s/ he had been threatened on two occasions by different patients. Although the patient was transferred to the other unit, this 2nd unit was where all three patients participated in programs. The Psychiatric Transfer Note also referred to another incident on 6/14/12. He was noted to be a client of DDS (Developmental Disabilities Services).

c. The 7/3/12 Psychiatric Progress Note stated that the patient "was not prescribed any standing doses of psychotropic medications at this time." The patient was offered medication treatment for ADHD symptoms but declined it.

d. The Integrated Treatment Plan dated 7/3/12 stated, "In the opinion of the treatment team, the patient is not ready for discharge because: [s/he] is a client of DDS and this agency is responsible for establishing a discharge plan ...." The listed interventions were minimal in frequency, with no evidence that the modalities were therapeutic rather than diversional or educational: "Art therapy sessions( 60 minutes weekly)"; "Let ' s Talk group(60 minutes weekly)"; "gardening( 60 minutes weekly)"; "movie night (120 minutes weekly)" ; "fitness (45 minutes three times per week)" ; "Be the best you can be group (30 minutes weekly)"; "Mastering Workplace Success group (60 minutes twice weekly)" and "120 minutes of OT as needed."

2. Interviews

In an interview on 7/10/12 at 3:30 p.m., the Program Manager explained that the facility had been directed to admit the patient despite the inappropriateness for psychiatric hospitalization due to his/her intellectual disability. Additionally the hospital could not discharge the patient without the cooperation of DDS in developing and implementing a discharge plan which included housing.

B. Patient #110

1. Record Review

a. The "Annual Psychiatric Review" for Patient #110, dated 5/7/12, stated that the patient remains committed to the Psychiatric Security Review Board. It also stated, "There were no signs of affective disorder or psychosis. There were no incidents of physical aggression towards self or others this year..... [S/he] is not prescribed any psychotropic medications, and none are indicated." Regarding discharge, the review stated, "At this time, [his/her] transition to community living is stalled pending a decision by the PSRB [Psychiatric Security Review Board] on the hospital's application."

b. According to the Integrated Treatment Plan dated 7/3/12, the patient was found NGRI [not guilty by reason of insanity] of the crimes of sexual assault and was admitted to the hospital on 5/8/1996. S/he was under the jurisdiction of the Psychiatric Security Review Board (PSRB). Additionally, the plan stated that the patient, "remained free of any incidents of physical aggression toward self or others this month... remained psychiatrically stable... there was no evidence of psychosis or affective disorder.... [S/he] does not take any psychotropic medications... there were no psychiatric risk issues this month.... [S/he] continued to attend PSRB group and the rest of [his/her] activities at the hospital involved health walks and leisure activities." The discharge criteria listed on the treatment plan consisted of: [patient] "needs to successfully complete a trial period of overnight TL's before [s/he] can be considered a candidate for conditional release, i.e., discharge by the PSRB." The groups/activities identified in the plan consisted of diversional and/or educational activities, with limited frequency: PSRB group which meets weekly for one hour with the social worker, monthly 15 minute meetings with the psychiatrist to evaluate changes in the patient's mental status, weekly 30 minute meetings with the RN to discuss the patient ' s legal status, and monthly 30 minute meetings with the social worker to discuss discharge planning. The only other activities identified on the treatment plan were weekly billiards, weekly AA meetings, health walks 4 times per week, weekly physical therapy for weight loss, and "as needed" health education.

c. The Quarterly Psychiatric progress note dated 6/1/12 stated that a PSRB hearing was held on 4/13/12, and that the hospital received a MOD (modification in release request) dated 5/8/12 by which the hospital was informed that more information was needed about the patient's social relationships and financial dealings. No information about when the information was secured or submitted was identified.

2. Interview

In an interview on 7/10/12 2:35 p.m., Patient #110 stated that s/he believed s/he no longer needed to be in the hospital and that s/he was being "warehoused." S/he stated that the only benefit s/he derived from the hospital was work opportunity and s/he believes s/he is being discriminated against based on his/her past crime. S/he stated that s/he saw the psychiatrist about once per month for about 15 minutes and that his/her only therapies consisted of AA once per week and PSRB group. S/he stated that s/he did not see a psychologist on a regular basis and saw the social worker only when s/he needed to. S/he reported that s/he received no specialized counseling.

C. Patient #111

1. Record Review

a. The Annual Psychiatric Review for Patient #111, dated 11/12/11, stated that the patient "has made no change in the last year and remains hospitalized because of the risk of sexual molestation of children ...the patient has never acknowledged [the] crime." The listed current interventions were: Review Board group, Community Process, Newsletter Bingo, Billiards, Coffeehouse, Movie Night and Library Group. Additionally, the review stated, "Patient was found NGRI of the crimes of Sexual Assault and Risk of Injury to a Minor and committed to the PSRB for 15 years." The commitment was later extended.

b. The Integrated Treatment Plan dated 6/6/12 identified the patient was found NGRI of the crimes of sexual assault and risk of injury to a minor. The patient was committed to the Psychiatric Security Review Board (PSRB) for a term of 15 years on 11/14/1994. The treatment plan stated that the patient remained free of psychotic and affective features again this quarter. "[Patient] does not take any psychotropic medication and has not since 3/8/2012, as there are none indicated for [the] problem." "Discharge planning remains through the DMHAS ABI/TBI service." "In the opinion of the treatment team the patient was ready for discharge because of the following factors: The ABI/TBI team has located a residential placement for [the patient] which will be staffed 24 hours per day. The team is preparing an application for conditional release to submit to the PSRB for approval."

c. The Monthly Psychiatric Progress Note dated 1/4/12 stated that patient remained free of psychotic or affective features and did not take any psychotropic medication as none was indicated for [his/her] problem. The DMHAS/TBI team has been exploring possibly residential options. The Monthly Psychiatry Progress Note dated 7/2/12 repeated the same information.

2. Interview

An interview with Psychologist 1 on 7/11/12 at 2:45 p.m. revealed that the active treatment involvement is limited to leisure and recreational pursuits such as library visits. Psychologist 1 stated that the patient can no longer benefit from inpatient psychiatric treatment due to cognitive limitations secondary to Traumatic Brain Injury and progressive dementia. She stated that the patient could be safely housed in a supervised residential setting in the community.

Based on policy review, record review and interview, the facility failed to ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge per the facility's policy in 4 of 8 discharge records reviewed (#118, 119, 120 and 124). This deficiency results in a failure to communicate in a timely manner the final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers.

Findings include:

A. Policy Review

Facility Policy II-9-9.7, last revised 5/23/11, noted under the section titled "Policy" stated: "To insure continuity of patient care and assist other physicians who may be treating the patient, all medical records will be completed within 30 days of the patient's discharge from CVH."

Under the section titled "Procedure" stated: "A Discharge Summary is to be dictated/written by the Physician/Psychiatrist within 15 days of discharge. All required signatures are to be obtained within 30 days of discharge."

B. Record Review

1. Patient #118: discharged 5/22/12; Discharge Summary dated 7/10/12 (19 days late).

2. Patient #119: discharged 5/17/12; Discharge Summary dated 7/10/12 (24 days late)

3. Patient #120: discharged 5/24/12; Discharge Summary dated 7/6/12 (13 days late)

4. Patient #124: discharged 5/9/12; Discharge Summary dated 6/18/12 (10 days late)

C. Interview

In an interview on 7/11/12 at 2:15 p.m., the Medical Director was shown all four discharge summaries noted above and agreed with the findings.

Based on record review and interview, the facility failed to ensure that discharge summaries contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 7 of 8 discharged patients whose records were reviewed (#118, 120, 121, 122, 123, 124 and 125). Additionally, the physician dictation for two patient records (#119 and #120) was completed after the scheduled outpatient appointment follow up date. This results in a lack of critical clinical information, indicating the patient's level of psychiatric symptomatology and risk, being available to aftercare providers.

Findings include:

A. Record Review

1. Patient #118, discharged 5/22/12. The Discharge Summary dated 7/10/12, under the section titled "Discharge/aftercare plan and treatment recommendations," noted only information related to outpatient care follow-up agencies and halfway house placement. There was no information within the entire Discharge Summary that related to treatment recommendations.

2. Patient #119, discharged 5/17/12. The Discharge Summary dated 7/10/12, under the section titled "Discharge/aftercare plan and treatment recommendations" only noted information related to outpatient care follow-up agencies, with an appointment dated 5/21/12.

3. Patient #120, discharged 5/24/12. The Discharge Summary dated 7/6/12, under the section titled "Discharge/aftercare plan and treatment recommendations" noted only information related to outpatient care follow-up agencies, with appointments dated 5/31/12 and 6/14/12. There was no information within the entire Discharge Summary that related to treatment recommendations.

4. Patient #121, discharged 5/9/12. A handwritten Discharge Summary dated 5/9/12 did not contain any information related to treatment recommendations after discharge.

5. Patient #122, discharged 5/25/12. The Discharge Summary dated 5/25/12, under the section titled "Discharge/aftercare plan and treatment recommendations" noted only information related to outpatient care follow-up agencies. There was no information within the entire Discharge Summary that related to treatment recommendations.

6. Patient #123, discharged 5/1/12. The Discharge Summary dated 5/1/12, under the section titled "Discharge/aftercare plan and treatment recommendations" noted only information related to outpatient care follow-up agencies. There was no information within the entire Discharge Summary that related to treatment recommendations.

7. Patient #124, discharged 5/9/12. The Discharge Summary dated 6/18/12, under the section titled "Discharge/aftercare plan and treatment recommendations" noted only information related to competency to stand trial. There was no information within the entire Discharge Summary that related to treatment recommendations or outpatient follow up.

8. Patient #125, discharged 5/3/12. The Discharge Summary dated 5/17/12, under the section titled "Discharge/aftercare plan and treatment recommendations" noted only information related to outpatient care follow-up agencies. There was no information within the entire Discharge Summary that related to treatment recommendations.

B. Interview

In an interview on 7/11/12 at 2:15 p.m., the Medical Director was shown examples of the above deficiencies for patients 118, 119, 120, 121 and 124). He agreed with the findings.

Based on record review and interviews, the Medical Director failed to:

I. Ensure that staff provided active psychiatric treatment, including alternative interventions, for 1 of 1 active sample patient (#100) on the Traumatic Brain Injury Unit, and 1 of 3 active sample patients (#102) on the Geriatric Unit, who were either not cognitively capable of participating in treatment and/or were not motivated to attend their assigned treatment groups. Failure to provide active treatment for patients results in the patients being hospitalized without all interventions for recovery being provided for them, potentially delaying their improvement. (Refer to B125-I)

II. Ensure that staff provided individualized treatment based on the presenting needs of 1 of 18 active sample patients (#105). This patient failed to attend most of the modalities listed on the treatment plan, and was observed to be in bed alone, during the times group treatments were taking place. Although interview and record review revealed staff were aware that the patients were not utilizing the modalities designated on their plans for their treatment, the staff did not develop alternative treatment modalities to meet this patient's needs. Failure to provide active treatment results in patients being hospitalized without all interventions for recovery being provided. This potentially delays their improvement. (Refer to B125-II)

III. Ensure that staff discharged 3 of 4 forensic division active sample patients (#109, 110 and 111) patients to a less restrictive level of care in a timely manner. Two of these patients (#109 and #111) had significant cognitive impairments (#109 and 111) but had reached stability in psychiatric symptoms and no longer required acute hospital care. The third patient (#110) lacked documentation of the need for inpatient psychiatric treatment. These patients were retained due to circumstances unrelated to their psychiatric needs. The medical record documentation for patients #109 and #111 failed to demonstrate that inpatient services were of an intensity and frequency to justify the more restrictive level of care. Documentations for Patient #109, who had developmental disabilities, also revealed concerns about managing his/her safety on a unit that served forensic patients who could and did threaten his/her safety. These failed practices impinge on patients' rights to be treated in the least restrictive setting appropriate to their needs and absorbs staff time which should be directed to the acute patients. (Refer to B125-III)

IV. Ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge per the facility's policy in 4 of 8 discharge records reviewed (118, 119, 120 and 124). This deficiency results in a failure to communicate in a timely manner final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers. (Refer to B133)

V. Ensure that discharge summaries contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge for 7 of 8 discharged patients whose records were reviewed (118, 120, 121, 122, 123, 124 and 125). Additionally, the physician dictation for two patient records (119 and 120) was completed after the scheduled outpatient appointment follow up date. This results in a lack of critical clinical information, indicating the patient's level of psychiatric symptomatology and risk, being available to aftercare providers. (Refer to B134)

Based on interview and document review, the Social Work Director failed to assure effective discharge planning for patients. This resulted in 3 of 4 active sample patients in the forensic division (#109, 110 and 111), who no longer required acute hospital care, not being discharged in a timely way. Two of these patients (#109 and 111) had significant cognitive impairments but had reached stability in psychiatric symptoms and no longer required acute hospital care. The third patient (#110) lacked psychiatric symptoms with documented need for inpatient psychiatric treatment. These patients were retained because of circumstances unrelated to their psychiatric needs. Failure to manage the discharge planning of patients who are not in need of inpatient psychiatric treatment results in failure to treat patients in the least restrictive setting appropriate to their needs, and absorbs staff time which should be directed to caring for patients needing acute psychiatric care.

Findings include:

A. Document Review

The facility's "Operational Procedural Manual Section III: Structures with Functions Policy 12: Social Work Procedure 12.a.15: Performance Improvement Plan Discharge Planning and Community Integration 2011-2012" states, "Clinical Social Workers...are charged with the oversight responsibility for discharge planning and therefore play a vital role on the treatment team. Discharge planning data is routinely collected and summarized by the Social Work Director and reported on in Clinical Management Committee and the hospital's Governing Body."

B. Specific Patient Findings

1. Patient #109

a. Record Review

1) According to the Integrated Psychiatric Assessment dated 4/16/12, Patient #109 was a young adult who was never previously hospitalized. The patient was transferred from a correctional institution. The assessment indicated some confusion regarding the patient's criminal obligations, which resulted in a civil commitment to the hospital ' s forensic division.

2) The patient's scheduled activities revealed no therapeutic services: Level 3B privileges, 2 hours/ week in gardening, and unit activities. S/he was noted to be a client of DDS (Developmental Disabilities Services).

3) The Integrated Treatment Plan dated 7/3/12 stated, "In the opinion of the treatment team, the patient is not ready for discharge because: [s/he] is a client of DDS and this agency is responsible for establishing a discharge plan. The agency is reportedly actively seeking an apartment setting for placement after which staff will need to be hired and trained; patient is not able to return to [his/her] mother's home; and, has a criminal court appearance on 8/24/12."

B. Interviews

In interview on 7/10/12 at 3:30 p.m., the Program Manager explained that the facility had been directed to admit the patient despite the inappropriateness for psychiatric hospitalization due to his/her intellectual disability. Additionally the hospital could not discharge the patient without the cooperation of DDS in developing and implementing a discharge plan which included housing.

B. Patient #110

1. Record Review

a. The "Annual Psychiatric Review" dated 5/7/12 stated that the patient remained committed to the Psychiatric Security Review Board. "There were no signs of affective disorder or psychosis. There were no incidents of physical aggression towards self or others this year.... [S/he] is not prescribed any psychotropic medications, and none are indicated." Regarding discharge, "at this time, [his/her] transition to community living is stalled pending a decision by the PSRB on the hospital's application."

b. According to the Integrated Treatment Plan dated 7/3/12 the patient was found NGRI and was admitted to the hospital on 5/8/1996. S/he is under the jurisdiction of the Psychiatric Security Review Board (PSRB). The discharge criteria listed on the treatment plan consisted of: patient "needs to successfully complete a trial period of overnight TL's before [s/he] can be considered a candidate for conditional release, i.e., discharge by the PSRB. During these trial periods [s/he] must demonstrate full compliance with all requirements in [his/her] Modification of Release Request (MOD) from the Board so that the community, the Board and the hospital agree that [his/her] risks can be safely managed in the community."

c. The Quarterly Psychiatric progress note dated 6/1/12 stated that a PSRB hearing was held on 4/13/12 and that the hospital received a MOD (modification in release request) dated 5/8/12 by which the hospital was informed that more information was needed about the patient's social relationships and financial dealings. No information about when the information was secured or submitted was identified.

2. Interviews

In an interview on 7/10/12 at 2:35 p.m., Patient #110 stated that s/he believed s/he no longer needed to be in the hospital and that s/he was being "warehoused." S/he stated that the only benefit s/he derived from the hospital was work opportunity and s/he believed s/he was being discriminated against based on his/her past crime. S/he stated that s/he saw the psychiatrist about once per month for about 15 minutes and that his/her only therapies consisted of AA once per week and PSRB group. S/he stated that s/he did not see a psychologist on a regular basis and saw the social worker only when s/he needed to. S/he reported that s/he received no specialized counseling.

C. Patient #111

1. Record Review

a. The Annual Psychiatric Review dated 11/12/11 stated that the patient "has made no change in the last year and remains hospitalized because of the risk of sexual molestation of children.....the patient has never acknowledged [the] crime."

b. The Integrated Treatment Plan dated 6/6/12 identified the patient was committed to the Psychiatric Security Review Board (PSRB) for a term of 15 years on 11/14/1994. The plan stated that the patient remained free of psychotic and affective features again "this quarter." "Discharge planning remains through the DMHAS ABI/TBI service." "In the opinion of the treatment team the patient was ready for discharge because of the following factors: The ABI/TBI team has located a residential placement for [the patient] which will be staffed 24 hours per day. The team is preparing an application for conditional release to submit to the PSRB for approval."

c. The Monthly Psychiatric Progress Note dated 1/4/12 stated that the DMHAS/TBI team has been exploring possibly residential options. The Monthly Psychiatry Progress Note dated 7/2/12 repeated the same information.

2. Interview

In an interview on 7/11/12 at 2:45 p.m., Psychologist 1 stated that the patient can no longer benefit from inpatient psychiatric treatment due to cognitive limitations secondary to Traumatic Brain Injury and progressive dementia. She stated that the patient could be safely housed in a supervised residential setting in the community.

1. Based on a review of clinical records, interview and review of policy, the facility failed to ensure that 9 of 21 patient's (Patients #36, 29, 39, 28, 42, 47, 51, 52 and 105) had comprehensive and/or individualized treatment plans to meet the needs of the patient and/or that the plans were reviewed. The findings include the following:


a. Review of Patient #36's clinical record indicated that the patient had been admitted to the facility on 8/19/11 with bipolar and schizoaffective disorders. The clinical record indicated that the patient was transferred to Woodward 2 north on 7/6/12. The clinical record indicated that since the move the patient had been experiencing an increase in agitation. Review of the treatment plan completed 6/26/12 failed to address the patient's transfer/move.


b. Patient #29 has diagnoses that included end stage renal disease (ESRD) requiring hemo dialysis three times a week, diabetes, bilateral above the knee amputations, MRSA and required non-invasive ventilation (CPAP). Review of the treatment plans dated 5/9/12 and 7/2/12 failed to reflect that the patients need for hemodialysis and non invasive ventilation had been addressed.


c. Patient #39 was admitted with diagnoses including schizoaffective disorder and borderline personality. The clinical record indicated that the patient had fallen on 6/19/12 and 6/24/12. The monthly treatment plan completed on 6/24/12 indicated that the patient was a fall risk with interventions that included reevaluate patient for change of condition, notify MD and PT as needed, assist with ADL's, and monitor for gait changes. On 7/2/12, the patient fell resulting in right arm pain. The monthly treatment plan dated 7/6/12 identified the patient was a fall risk with the same interventions identified. The ITP failed reflect that the plan had been reviewed subsequent to the falls the patient experienced in June and July.


d. Patient #28 had a history of violent, aggressive behaviors and had been receiving electroconvulsant therapy (ECT) with positive results. The record indicated the patient had an eight month period with no episodes of aggressive behaviors with ECT stopped approximately one month ago due to the discovery the patient had multiple questionable area's in his/her lung that required medical evaluation. The record identified that the patient was involved in eight episodes of aggressive behaviors requiring staff intervention resulting in patient and/or staff injuries. Review of the ITP dated 6/6/12 identified the objective that the patient will continue to manage impulses to attack and/or hit others. The focused ITP's dated 6/11/12 and 6/22/12 identified the same problems/objectives however the focused ITP failed to reflect additional interventions, plans and/or services to assist the patient to achieve the identified objective. The ITP failed to identify the reason for the focused review as well.

In addition under the patients active medical problems Rhinitis, acid reflux and hypercholesterolemia were the only problems identified. The ITP failed to address the patients lung masses and/or the cessation of ECT as a result.


e. Patient #47 had diagnoses that included schizoaffective disorder and polysubstance abuse. The clinical record indicated that in December of 2011, the Patient experienced a significant weight loss over a six week period. The clinical record identfied that the patient's weight in January 2012 was 189. A physician's order dated 5/24/12 directed a puree diet with Enlive 3-4 times a day. A nutrition consult dated 5/30/12 identfied recommendations to add milk, yogurt, cottage cheese to the trays, and Glucerna supplements. An order dated 6/21/12 directed a chopped diet with Enlive (supplement). Although the ITP dated 6/29/12 identified an active problem for weight loss that identified the patient was on Glucerna 1.5 as needed if patient consumes less then 50% of meal and one at snack time. The record failed to reflect an order for the Glucerna rendering the plan inaccurate. Additional intervention's noted on the plan included educate patient on food choices, weigh per MD orders (weekly), and inform MD and/or dietician of concerns. The facility failed to ensure that the ITP was accurate and/or individualized to meet the needs of the patient. Subsequent to surveyor inquiry, the patient's weight was obtained on 7/11/12 and documented as 167 pounds, a 22 pound weight loss since January.


f. Patient #105 was admitted to the facility on 5/1/12 with diagnoses that included depression and suicidal ideation. A physician's order dated 5/1/12 directed a regular diet. The RD's note dated 5/2/12 identified that the patient was underweight by body mass index (BMI), weighed 120 lbs with an ideal body weight of 170 lbs. and required 2400 calories per day. The patient was noted to have poor fluid and food intake secondary to depression. The Dietician recommended a tender diet with soft fruits, vegetables, yogurt, supplements and to monitor oral intake for seven days. A physicians order dated 5/2/12 agreed with the RD recommendations.

Review of the treatment plans dated 5/21/12, 5/25/12, 5/29/12, 6/4/12, and 6/18/12 failed to identify that an individualized plan of care was developed to address the patient's risk for weight loss and/or dehydration.


The clinical record indicated that on 6/7/12 the patients weight was 124. The next documented weight on 6/28/12 identified that patient weighed 121, a three pound weight loss.


Review of the I&O sheets for the period of 5/2/12 through 7/11/12 (64 days) identfied that on 56 days the patient had a fluid intake of 500 cc's or less documented. Based on the patient's weight of 120 pounds on 5/1/12, the patient required 1,636 cc's of fluid daily to maintain hydration. The facility failed to ensure that I&O was consistently monitored as ordered and/or that the patient was assessed for signs and symptoms of dehydration when suboptimal intake was documented.


Review of the facility policy "Integrated Treatment Planning Process" identified a focused treatment plan should be completed when there is a change in condition and the plan should be focused on alterations necessitated by the change in condition. Review of the Nutritional Assessment policy indicated that a comprehensive risk assessment is performed by a dietician on all admissions. The policy identified that the Dieticians will ensure that pertinent nutritional information from the assessment will be integrated into the treatment plan.

g. Patient #51 was admitted to the hospital on 7/7/12 for detoxification and rehabilitation from alcohol. Patient #51 ' s diagnosis included alcohol dependence, depressive disorder and severe peripheral vascular disease. Review of the clinical record identified Patient #51 was scheduled for vascular surgery in approximately two weeks. Interview and review of the clinical record with the Director of Nursing on 7/11/12 at 11:00 AM indicated the treatment plan failed to identify peripheral vascular disease as an active problem with interventions that were individualized for Patient #51.
h. Patient #52 was admitted to the hospital on 6/26/12 for detoxification and rehabilitation from alcohol dependence. Patient #52 ' s diagnosis included alcohol abuse and schizoaffective disorder. Interview and review of the clinical record with the Director of Nursing on 7/11/12 at 11:15 AM indicated the treatment plan failed to identify schizoaffective disorder as an active problem with interventions that were individualized for Patient #52.
i. Patient # 42 was admitted to the hospital on 5/22/12 from the court for competency restoration. Patient #42 ' s diagnosis included obsessive compulsive disorder, psychotic symptoms and substance abuse. Interview and review of the clinical record with Nurse Manager #2 on 7/10/12 at 1:15 PM identified when Patient #42 interacted with family members he/she was agitated and demonstrated hostile behaviors intermittently requiring immediate interventions to prevent imminent risk to others. Further review of the clinical record failed to identify a plan of care with intervent

Based on a review of clinical records, interviews and review of facility policy for two patients reviewed for hydration (#30 and 105), the facility failed to provide sufficient fluid to maintain proper hydration and/or for two of three patients with altered nutrition (#47 and 105), the facility failed to ensure that physician orders for supplements were implemented and/or that weights were monitored in accordance with the MD order and/or for one patient reviewed with pressure ulcers (#47), the facility failed to ensure that wounds were monitored per facility policy and/or for two of two patients (P #51 and P#42), the facility failed to assess an active medical condition, and/or conduct an accurate mental status assessment, and/or for one sampled patient (P #44), the facility failed to complete an annual fall assessment, and/or provide an intervention to prevent an injury, and/or document an assessment of the injury in the medical record and/or the facility failed to implement a consistent and/or comprehensive allowable item/suicide risk policy. The findings include:

a. Patient #30 was admitted on 4/23/12 with diagnoses that included schizoaffective disorder with a history of numerous suicide attempts resulting in triple limb amputations. Review of the progress notes identified that the patient was inpatient in an acute care facility from 6/20/12-6/22/12 with hypernatremia.


Review of the I&O record during the period of 6/23/12-6/26/12 identified that the patient's consumed fluids "occ" (for occasional), and/or zero, with zero fluid intake on 6/25/12, and 1430 cc intake on 6/26/12. The total 24-hour I&O was not calculated for any of those days.

The progress notes indicated that the patient was moved from Merrit Hall to Batell on 6/26/12.

Review of the I&O record identfied that the patient consumed 960 cc's of fluid on 6/27/12 and 240 cc's on 6/28/12. No urinary output was documented. The total 24-hour I&O was not calculated for those days.


A physician's order dated 6/29/12 directed to encourage electrolyte drinks and encourage oral intake. Review of the progress notes dated 6/27/12 through 7/9/12 identified repeatedly that Patient #30 was refusing food and fluids. The order dated 7/2/12 directed intake and output (I&O) for seven days and the order dated 7/6/12 directed to monitor I&O.

Review of the treatment plan dated 7/3/12 identified a problem for refusal of food and fluids with interventions that included in part, APRN to monitor patient's state of hydration and nutrition, follow input, vitals signs, labwork as indicated, collaborate with RNs and psychiatrist around issues of care in order to maintain adequate hydration and nutrition status. Nursing is responsible to monitor I&O every shift, offer fluids hourly, monitor vital signs every shift, electrolytes per MD order, and monitor for mental status changes. A "please monitor me for s/s of dehydration", document was located in the record that explained symptoms of mild, moderate, and severe dehydration with guidance for dehydration treatment.


Review of the I&O records during the period of 6/29/12 through 7/11/12, identified documentation that included, refused, occ (for occasional), and/or zero. The patient's fluid intake and/or urinary output was not calculated for the twenty-four hour periods as indicated on the I&O record to determine if the patient's fluid needs were met. The clinical record lacked evidence that dehydration assessments were conducted when the patient's I&O was insufficient.


Interview with staff on 7/10/12 at 2:30 PM indicated that the patient had refused all fluids and food since arrival to the floor on 6/27/12. The record reflected that the patient had been refusing vital signs, blood draws, food and fluid. On 7/11/12 the patient was sent to the ED for evaluation and was admitted for dehydration and remained hospitalized as of 7/12/12.


b. Patient #105 was admitted to the facility on 5/1/12 with diagnoses that included depression and suicidal ideation. A physician's order dated 5/1/12 directed a regular diet.

The Registered Dietician's (RD) note dated 5/2/12 identified that the patient was underweight by body mass index (BMI), weighted 120 lbs with an ideal body weight of 170 lbs. and required 2400 calories per day. The patient was noted to have poor fluid and food intake secondary to depression. The Dietician recommended a tender diet with soft fruits, vegetables, yogurt, supplements and to monitor oral intake for seven days. A physicians order dated 5/2/12 agreed with the RD's recommendations.

Review of the treatment plans dated 5/21/12, 5/25/12, 5/29/12, 6/4/12, and 6/18/12 failed to identify that the patient was underweight, was at risk for weight loss and/or dehydration.


A physician's order dated 5/29/12 directed "diet" and Glucerna, one can with meals if meals refused, and electrolyte replacement drink with meals. Review of the clinical record and interview with the Director of Psychiatry on 7/11/12 at 11:00 AM stated this order was not transcribed and/or that a specific diet was designated for the patient. The order dated 5/30/12 directed I&O monitoring for seven days, and an order dated 6/4/12, directed weekly weights.


The clinical record indicated that on 6/7/12 the patients weight was 124. The next documented weight on 6/28/12 identified that patient weighed 121, a three pound weight loss. The facility failed to ensure that weekly weights were obtained.


Additionally, review of the I&O sheets for the period of 5/2/12 through 7/11/12 (64 days) identfied that on 56 days the patient had a fluid intake of 500 cc's or less documented. Based on the patient's weight of 120 pounds on 5/1/12, the patient required 1,636 cc's of fluid daily to maintain hydration. The facility failed to ensure that I&O was consistently monitored as ordered and/or that the patient was assessed for signs and symptoms of dehydration when suboptimal intake was documented.



c. Patient #47 had diagnoses that included schizoaffective disorder and polysubstance abuse. Review of the clinical record indicated that the patient had a history of skin breakdown, was wheelchair bound and a Hoyer assist for transfers. Review of the ITP dated 6/29/12 identified an active problem for weight loss with interventions that included Glucerna 1.5 as needed if the patient consumes less then 50% of the meal and one at snack time, however the record failed to reflect an order for this, educate patient on food choices, weigh per MD orders, and inform MD and/or RD of concerns.


Review of the clinical record dated 5/2/12 reflected that a 2 cm by 2 cm pressure ulcer was observed on the sacrum, however, the assessment failed to identify staging of the wound. On 5/7/12, the wound was measured as 2 cm by 0.8 cm by 0.01 cm, absent of the staging. A new treatment order that directed to clean the coccyx open areas with normal saline, apply an aquacell dressing and change every 48 hours was obtained.

Review of the clinical record with the Director of General Psychiatry identfied that on 5/12/12, the coccyx/sacral wound was measured as 2 cm by 2 cm. The record failed to identify that the patient's pressure ulcer wound was next measured until 6/5/12 although the policy directs wound measurements weekly. The 6/5/12 assessment reflected that a new pressure ulcer had developed on the patient's left buttock (wound 1) that measured 3 cm by 2 cm and the existing pressure ulcer on the coccyx/sacrum (wound 2) was 2 cm by 2 cm.

The subsequent assessment dated 6/29/12, three weeks later, reflected that the buttock pressure ulcer (wound 1) had increased in size, measuring 3 cm by 2 cm by 0.25 cm and the sacral/coccyx pressure ulcer (wound 2) had also increased in size measuring 2 cm by 2 cm by 0.25 cm. The facility failed to ensure that weekly pressure ulcer wound assessments had been completed in accordance with facility policy.


Review of the Wound care policy directed that wounds would be measured (length, width and depth) weekly on Wednesdays. The policy indicated that wounds will be staged upon initial assessment.


d. Patient #47's record indi