HospitalInspections.org

30490

Based on patient observation, record review and interview the facility failed to develop Master Treatment Plans (MTPs) that clearly identified nursing interventions based on the patients' current behaviors/findings for eight (8) of eight (8) sample patients (A2, A23, A30, A33, B15, B25, C22 and C24). This hindered the provision of individualized nursing care for patients and failed to provide specific directions for non-professional nursing personnel (LPNs and Health Care Technicians/Psychiatric Care Specialists).

Findings include

A. Upon admission an Initial Nursing Treatment Plan was completed from preprinted lists of generic interventions for identified problems. The nurse identified the selected interventions by a check mark. None of the selected interventions were individualized with added information based on patient findings. During interview on 12/15/15 at 1:05 p.m. the CEO reported that the Initial Nursing Treatment Plan was voided at the time the initial Master Treatment Plan was developed.

B. Policy Review

Facility policy, titled "Plan for the Provision of Care" dated 2015 stated under section "V Services item C 1c," "Treatment planning is individualized according to individual needs identified through assessments. Primary assessments and re-assessments."

C. Patient Findings

1. Patient A2 was admitted on 12/12/15

a. According to the psychiatric evaluation (12/12/15), patient A2 was admitted for "Depression, danger to self and drug and alcohol abuse."

b. In Patient A2's MTP dated 12/13/15, for problem "depression with suicidal ideation with self harm and anxiety," no nursing interventions were noted for this identified problem.

2. Patient A23 was admitted on 12/09/15

a. According to the psychiatric evaluation (12/10/15), patient A23 was admitted for "Depression and danger to self."

b. In Patient A23's MTP dated 12/10/15, for problem "depression with suicidal ideation, " the only nursing intervention was "Med Education" with no specific duration noted.

3. Patient A30 was admitted on 12/8/15

a. According to the psychiatric evaluation (12/9/15), Patient A20 was admitted for, "Agitation resulting in significant loss of functioning with dangerous to self and others and need for controlled environment... [S/he] set a mattress in the basement on fire... (s/he) brought a BB gun to school."

b. In Patient A30's MTP (12/9/15), for problem, "Aggression with Harm to Self and Others," the only nursing interventions were education oriented. There were no nursing interventions to care for the patient in the clinical area including specific safety interventions based on [his/her] presenting findings.

4. Patient A33 was admitted on 12/2/15

a. According to the psychiatric evaluation (12/3/15), Patient A33 was "admitted due to anxiety, depression, dangerousness to self and having hallucinations...has had violent rages..."

b. During interview on 12/14/15 at 11:20 a.m., Patient A33 reported "last night was the first night that I have not had a nightmare about suicide."

c. In Patient A33's MTP (dated 12/3/15) for the problem stated as "Depression with Suicidal ideation and psychotic features, the only nursing interventions were education oriented. There were no nursing interventions to care for the patient in the clinical area including specific safety interventions based on (his/her) presenting findings."

5. Patient B15 was admitted on 12/9/15.

a. According to the psychiatric evaluation (12/9/15), this patient's "hospitalization was initiated by patient's mother indicating that (s/he) was disruptive and paranoid...saying that the people are putting poison in [his/her] food."

b. In Patient B15's MPT (dated 12/9/15) for the problem stated as "Depression with Suicidal ideation," there were no specific safety interventions based on nursing assessments that describe patient behaviors that nursing should watch for that might represent impending suicide in the milieu. The only preventive interventions listed were related to education of the patient regarding the importance of taking prescribed medication and the side effects of medication.

6. Patient B25 was admitted on 11/30/15.

a. According to the psychiatric evaluation (12/1/15) this patient "became combative and argumentative, threatening to hurt them (father and brother) and reported [s/he] took some one-and-half tablets of Seroquel, went to sleep and upon waking up, [s/he] became very combative with mother and boyfriend."

b. On observation of a patient group activity on 12/14/15 from 1:30 pm to 2:30 pm Patient B25 presented highly agitated behavior, pacing back and forth at the back of the group room and exited and returned several times.

c. During interviews on 12/14/15 at 1:10 p.m. and on 12/15/15 at 12:30 p.m....patient was agitated talking about how much s/he distrusted all people and how angry s/he was with his/her mother. On 12/14/15, the patient refused to continue the interview and presented highly agitated behavior.

d. The Master Treatment Plan dated 12/2/15 with review date of 12/10/15 for problems, "psychotic behaviors," "imminent risk of harming self" and "imminent risk of harming others," failed to identify specific interventions to direct nursing personnel's in the monitoring and care for the patient's current agitated and paranoid behavior presented in the ward environment.

e. During an interview with the Director of Nursing in reviewing sample Patient B25's MTP on 12/15/15 at 10:20 a.m.; she stated "I would have liked to see more individualization for this patient."

7. Patient C22 was admitted on 12/03/15

a. According to the psychiatric evaluation (12/04/15) Patient was admitted due to psychotic behaviors, "I told my dad he should've wore a condom and he called the police, I did not want to be born."

b. In interview with active sample patient C22 on 12/14/15 at 11:15 p.m. in the activity room on the unit, s/he expressed s/he does not want to talk about being here in the hospital s/he just wants to get out. "I don't like mixing with others; I am a loner."

c. In Patient C22's MTP dated 12/14/15, for problem "psychotic behaviors," no nursing intervention was noted for this identified problem.

8. Patient C24 was admitted on 11/24/15

a. According to the psychiatric evaluation (11/24/15) patient was agitated and aggressive and was threatening the family.

b. In interview with active sample patient C24 on 12/14/15 at 1:50 p.m. in the activity room on the unit, s/he expressed that s/he wants to get out of here. "All I need is my medications."

c. In Patient C24's MTP dated 11/27/15 for the problem "psychotic behaviors," no nursing intervention was noted for this identified problem.
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07813


Based on patient observation, record review and interview the Director of Nursing failed to ensure that individualized nursing interventions, including safety in the clinical area, were included in Master Treatment Plans (MTPs) for eight (8) of eight (8) sample patients (A2, A23, A30, A33, B15, B25, C22 and C24). This hindered the provision of individualized nursing care for patients and failed to provide specific directions for non-professional nursing personnel (LPNs and Health Care Technicians/Psychiatric Care Specialists).
(Refer to B122)