HospitalInspections.org

Based on record reviews, observations, hospital policies and interviews the facility failed to assure:

A. Care was provided in a safe setting to include:

1. Ensure the patients' rooms were clean.
2. Ensure furniture and fixtures were continually maintained and safe for the patients to use.
3. Ensure safety locks were not available for patient use in the patient care areas.
4. Ensure a patient's dignity and comfort were respected while in restraints, this affected Patient Identifer (PI) # 2.
5. Ensure the safety of a patient on the adolescent male unit, this affected PI # 4.

Refer to A 144 for findings.

B. Patients were free from abuse/ harassment. The facility failed to:

1. Document incident reports on patients who sustained an injury in the facility
2. Notify the physician of any injury to a patient in the facility
3. Treat the injury as necessary
4. Investigate all injuries sustained in the facility.

Refer to A 145 for findings.


C. The physician signed orders for restraint:

1. The physician signed and dated orders for restraints and
2. The time limit for the use of restraints was followed.

Refer to A 168 for findings.

This had the potential to affect all patients served by this facility.

Based on observation, review of medical records and interview with administrative staff it was determined the facility failed to:

1. Ensure the patients' rooms were clean.
2. Ensure furniture and fixtures were continually maintained and safe for the patients to use.
3. Ensure safety locks were not available for patient use in the patient care areas.
4. Ensure a patient's dignity and comfort were respected while in restraints, this affected Patient Identifer (PI) # 2.
5. Ensure the safety of a patient on the adolescent male unit, this affected PI # 4.

This affected 2 of 6 active patients and had the potential to affect all patients served.

Findings include:

Annual update for staff provided to the surveyor 10/27/11 at 9:30 AM, "

Quiet Room Rules: NO Patient is allowed in quiet room unless they are in restraints, seclusion or have a staff member sitting directly with them. This is a fire hazard due to the possibility of someone being locked inside. Time outs may be completed in patient's room with staff member monitoring... After use of the quiet room nurses and tech's are responsible for cleaning the bed and replacing the sheet."


During a tour of the facility on 10/25/11 at 8:30 AM, the surveyor observed on the adult patient ward in room 204 a twist lock on the outside of the door which would allow a patient to be locked into the bathroom with no way out. The bathroom floor was also observed to be flooded with some type of liquid and paper towels were all over the floor in front of the commode.

During a tour of the facility on 10/25/11 at 8:30 AM, the surveyor observed the seclusion room revealed no bathroom. The surveyor asked the staff nurse touring with her; how they would handle a patient who was in restraints or seclusion who needed to go to the bathroom. The response was, " We have bedpans for them to use."

During a tour of the facility on 10/25/11 at 8:30 AM, the surveyor observed in room 210 a twist lock on the outside of the door and the light was not working in the shower area as shown by the patient in the room.

During a tour of the facility on 10/25/11 at 8:30 AM, the surveyor observed observed the seclusion room # 207, the door was locked and a sheet on the bed which was soiled. The nurse accompanying the surveyors removed the sheet and asked the housekeeper to come clean the room.

During a tour of the children/ girls side on 10/25/11 at 9:05 AM, the surveyor observed the seclusion room with a sheet that had dried skin on the bed. The nurse manager accompanying the surveyor removed the sheet and called for housekeeping.

During a tour of the adolescent girls side on 10/25/11 at 9:25 AM, the surveyor observed the seclusion room with a soiled sheet on the bed and alcohol pads and packets on the air conditioner. The nurse manager accompanying the surveyor removed the sheet and called for housekeeping.

Patient findings:

1. PI # 2 was admitted to the girls adolescent unit 9/8/11 with a primary Axis I diagnosis of Major Depressive Disorder, recurrent no Psychotic Features and generalized Anxiety Disorder. On 10/4/11 a change in diagnosis was entered as Schizoaffective Disorder.

An order for restraint and seclusion date 10/8/11 at 2:50 PM documented the patient was placed in 5 point restraints.

The 10/8/11 nurses note documented on PI # 2, " 1450 Pt( patient) in room at window sill 1:1 observer with pt. She beat on window and got a piece of Plexiglass and attempted to scratch wrist. Glass confiscated. She then started to beat on the window yelling 'restrain me I want a shot'." 1500 Geodon 20 mg (milligrams) IM (intramuscular) left GM (gluteus maximus).

An order to continue restraint was obtained at 4:45 PM, the nurse documented, " 1645 order for restraint continuation r/t( related to) verbal aggression and threatening toward staff. States, ' I need to use the BR ( bathroom) but also states that I'm gonna stick my head in the toilet and drown myself '. Offered use of bed towels but pt refuses stating ' I wanna go to the BR'. 1700 continues to threaten and cuss staff at present. Very inappropriate talk... 1715 Diaper placed on pt for elimination purposes related to inability to ambulate to BR, leg restraints released for 5 minutes."

The patient was released from restraints at 1740.

In an interview 10/27/11 at 10:45 AM with the staff nurse involved Employee Identifier (EI) # 7 and the case manager, EI # 3 it was confirmed the patient was restrained from 1455 to 1740 and was in diapers from 1710 to 1740. The surveyor asked EI # 7 why the patient was not offered a bedpan or some other alternative beside placing her in diapers which would have adversely affected the dignity of this 15 year old patient. EI # 7 stated they did not have bedpans in the hospital and she offered to pad the bed with towels but the diapers seemed better and she protected her dignity when she put it under her.

2. PI # 4 was admitted to the boys adolescent unit 10/3/11 with a primary Axis I diagnosis of Bipolar Disorder and Impulse Control Disorder.

The nurses note dated 10/14/11 at 8:10 PM documented, " ... Multi-redirections for inappropriate behavior. A peer supposedly locked him in hygiene; he busted door open trying to get out. He stated he was claustrophic and didn't know he could easily open door with handle..."

In an interview with Employee Identifier (EI) # 5, Director of Clinical Services on 10/28/11 at 9:45 AM she was asked about the above incident. On 11/2/11, EI # 5 returned the following information about the above incident. The surveyor asked the location the patient was locked into. EI # 5's written response was," Hygiene closet. Episode was brief and pt (patient) could easily open door."

The hygiene closet is a locked closet in the hall which contains all of the patients hygiene products in baskets to take to the shower.

PI # 4 was not kept safe from other peers and placed in a closet against his will.

Based on review of medical records, facility policy and procedure and an interview it was determined in 4 of 7 medical records reviewed that:

1. The facility failed to document incident reports on patients who sustained an injury in the facility
2. Notify the physician of any injury to a patient in the facility
3. Treat the injury as necessary
4. Investigate all injuries sustained in the facility.

This had the potential to affect all patients in the facility and did affect Patient Identifier (PI) # 1, 2, 3 and 8.

Findings include:

Facility Policy: Quality Assurance Reporting

Purpose:
To provide a mechanism for reporting hospital occurrences related to patient/employee safety.

Policy:
All occurrences on or within Corporate property should be reported to an immediate supervisor/ physician and documented in the patient record when appropriate. A Quality Assurance Report will be completed and forwarded to the Risk Manager for follow-up.

The following occurrences should warrant completion of an Quality Assurance Report, but is not inclusive:
1. Patient injury, patient abuse, or patient emergency
2. Visitor injury
3. Employee injury
4. Falls
5. Injuries resulting from Restraint/ Seclusion


Patient findings:

1. PI # 1 was admitted to the children's unit 10/7/11 with a primary Axis I diagnosis of Major Depressive Disorder, Single Episode, Severe without Psychotic Features. An Axis III diagnosis of Head Lice and Burns to Right forearm.

The 10/19/11 nurses note documented an injury to the back of PI # 1. The documentation included, " ...Was upset and hiding under the bed another male peer went in because she had his ball and would not return it- he pulled her out and scraped her back- 6 inches x 5 inches long- surface abrasion- Dr... notified."

There was no incident report completed, no documentation of an assessment of the area or any treatment to the site.

2. PI # 2 was admitted to the girls adolescent unit 9/8/11 with a primary Axis I diagnosis of Major Depressive Disorder, recurrent no Psychotic Features, generalized Anxiety Disorder. On 10/4/11 a change in diagnosis was entered as Schizoaffective Disorder.

The 10/7/11 nurses note documented an injury to PI # 2. The documentation included, " 1735 PCT (patient care technician) states pt was at window went to sit on bed, when the tech noticed pt scratching wrist area. When tech (technician) walked over to pt she noticed a screw approximately 2 inches long in her hand that she had gotten out of the window sill. Screw confiscated from pt. Escorted to quiet room and placed in 5 pt restraints."

There was no incident report completed, no documentation of an assessment of the area or any treatment to the site.

The 10/8/11 nurses note documented an injury to PI # 2. The documentation included, " 1450 Pt in room at window sill 1:1 observer with pt. She beat on window and got a piece of Plexiglass and attempted to scratch wrist. Glass confiscated. She then started to beat on the window yelling 'restrain me I want a shot'."

There was no incident report completed, no documentation of an assessment of the area or any treatment to the site.

3. PI # 3 was admitted to the girls adolescent unit 7/14/11 with a primary Axis I diagnosis of Bipolar Disorder not otherwise specified,
Impulse Control Disorder, and Conduct Disorder.

The 10/2/11 nurses note documented an injury to PI # 3. The documentation included, "..Pt has several small superficial cuts on upper arm. Pt said she did this yesterday because she was agitated at a female peer."

The 10/6/11 nurses note documented an injury to PI # 3. The documentation included, " ...went to room hit windows and slammed door, took a piece of plastic from her laundry basket and superficially scratched her left forearm... Laundry basket and harmful's removed from room."

There was no incident report completed, no documentation of an assessment of the area or any treatment to the site.

There was no incident report completed, no documentation of an assessment of the area or any treatment to the site.

The 10/10/11 restraint/ seclusion order form documented an injury to PI # 3. The documentation on the restraint/seclusion form documented, "... banging head on floor and sustained a small cut on left cheek with small amount of bleeding..."

There was no incident report completed, no documentation of an assessment of the area or any treatment to the site.

In an interview with PI # 3, the case manager, on 10/28/11 at 11:30 AM, EI # 3 confirmed there were no incident reports on the above incidents.



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4. PI # 8 was admitted to the facility on 9/21/11 with diagnoses including Bipolar and Impulsive.

Review of the Fifteen Minute Hall Check dated 9/24/11 at 5:00 to 5:30 PM revealed documentation the patient was biting and fighting.

Restraint/Seclusion Protocol MD (medical doctor) Order dated 10/14/11 at 5:30 revealed documentation of two staff members injuries. The patient was flailing her/his arms and caused a lock to cut one staff members index finger on the left hand and one staff got a scratch on the right hand.

Restraint/Seclusion Protocol MD Order dated 10/20/11 at 4:55 PM revealed documentation the patient had an injury during restraint or seclusion which included the patient jerked the right upper leg and the needle scratched the leg.

The surveyor requested an incident report for the above and none was submitted prior to the end of the survey.

Based on a review of medical records, facility policy and procedures and interview with Employee Identifer (EI) # 3 the Nurse Manager it was determined the facility failed to assure:
1. The physician signed and dated orders for restraints and
2. The time limit for the use of restraints was followed.

This had the potential to affect all patients served by this facility and did affect Patient Identifer (PI) #1, 2, 3 and 8.

Facility Policy: Restraints and Seclusion

Section Three: Physician Orders for Restraint and Seclusion and Evaluation

If the Registered Nurse (RN) initiates the restraint or seclusion, as soon as possible, but no longer than one hour, the Registered Nurse must notify and Obtain an order from the Psychiatrist... The Psychiatrist or trained Registered Nurse will do the following:
1. Reviews with the RN the physical and psychological status of the patient.
2. Determine whether restraint or seclusion should be maintained.
3. Supplies staff with guidance in identifying ways to help the patient regain control so that restraint or seclusion can be discontinued.
4. Supplies a time-limited order.

At the time of the in-person evaluation, the Psychiatrist, Nurse Practitioner or the trained Registered Nurse does the following:
1. Works with the patient and the staff to identify ways to help the patient regain control.
2. Revises the patient's plan for care, treatment and services as needed
3. If necessary, provides/ obtains a new written order.

Time-limited orders: Orders for restraint and seclusion are limited to:
4 hours for patient 18 and older
2 hours for children and adolescents age 9 to 17
1 hour for children less than 9 years old.
Time-limited orders do not mean that the patient must be in restraints or seclusion for the entire time period. The time limit represents the maximum amount of time for the order before the patient is re-evaluated. Restraints or seclusion should be terminated as soon as the patient meets behavior criteria for discontinuation.

Facility Policy: Physician's Orders
Procedure:
C. Verbal and telephone orders must be authenticated within twenty-four hours.

Patient Findings:

1. PI # 1 was admitted to the children's unit 10/7/11 with a primary Axis I diagnosis of Major Depressive Disorder, Single Episode, Severe without Psychotic Features. An Axis III diagnosis of Head Lice and Burns to Right forearm.

The 10/19/11 nurses note documented at 5:30 PM, " Pt in quiet room with RN (Registered Nurse) for 20 minutes."

There was no order for the patient to be in the quiet (seclusion) room in the medical record. The 20 minutes exceeds what is recommended for a 7 year old.

The 10/20/11 nurses note documented at 8:15 AM, " Pitching anger outburst, rolling in floor placed in seclusion with door locked to ofc( office?) with RN till pt able to calm herself p (after) 12 minutes, got up in chair started asking questions."
There was no order for the patient to be in the quiet (seclusion) room in the medical record.

In an interview on 10/27/11 at 10:35 AM with EI # 3, the RN Case Manager stated that the nurse should have written an order for 10/20/11 when taken to the seclusion room and the paperwork should have been completed.

No additional documentation was received prior to the exit.

2. PI # 2 was admitted to the girls adolescent unit 9/8/11 with a primary Axis I diagnosis of Major Depressive Disorder, recurrent no Psychotic Features, generalized Anxiety Disorder. On 10/4/11 a change in diagnosis was entered as Schizoaffective Disorder.

The restraint/ seclusion order form dated 10/6/11 at 3:40 PM placed the patient in 5 point restraints for a time limit of 2 hours. The patient received Geodon 10 mg ( milligrams) IM (intramuscular) at 4:00 PM. The patient continued to be agitated and a new order was added to the front of the restraint/ seclusion for at 5:30 PM-... Geodon 10 mg. The patient received the 2nd dose of Geodon at 5:40 PM. The patient was released from restraints at 7:00 AM. This 15 year old patient remained in restraints 3 hours and 20 minutes.

In an interview with Employee Identifier (EI) # 3, the case manager on 10/27/11 at 10:45 AM it was confirmed the patient was in restraints greater than 2 hours. EI # 3 stated that the nurse probably meant the medication order to be the extension order.

The restraint/seclusion order form dated 10/9/11 at 8:00 AM for 5 point restraints was signed by the physician. There is no date or time present when the nurse wrote the order or when the physician signed it.

The restraint seclusion order form dated 10/16/11 at 6:00 PM documented the patient was placed in 4 point restraints, the order was marked for 2 hours time limit. The narrative documentation documented at 8:00 PM- pt continues to verbalize SI (suicidal ideation). Continue in 4 pt (point) restraints. 8:15 PM, Dr... notified, received order by phone to continue 4 pt restraints x 2 hours or prn( as needed).

The restraint/ seclusion order form dated 10/20/11 at 1:00 PM documented this 15 year old patient remained in 5 point restraints until 3:00 PM. There was no time limit on the order.

3. PI # 3 was admitted to the girls adolescent unit 7/14/11 with a primary Axis I diagnosis of Bipolar Disorder not otherwise specified,
Impulse Control Disorder, and Conduct Disorder.

A restraint/seclusion order was in the medical record dated 10/24/11, written at 1:10 PM and marked for 2 hour restraint use on this 11 year old. The narrative description of the event documented, " 1310 pt escorted from classroom for disruptive and disrespective behaviors... 5 point restraints initiated for safety at 1325."

The patient was released from restraint at 1535 which is greater than 2 hours.




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4. PI # 8 was admitted to the facility on 9/21/11 with diagnoses including Bipolar and Impulsive.

Review of the Restraint/Seclusion Protocol MD Orders dated 9/27/11 at 8:25 AM, 9/29/11 at 8:00 AM, 9/30/11 at 8:00 AM, 9/30/11 at 2:25 PM, and 10/2/11 at 7:45 PM revealed no documentation of the date and time the physician signed the orders.

Review of the Nursing Reassessment dated 10/5/11 at 9:05 PM revealed the patient continued to escalate requiring 5 point leather restraints. There was no documentation of Restraint/Seclusion Protocol MD Order.

An interview was conducted on 10/27/11 at 11:20 AM with EI # 4, a RN, who verified the above.

Based on a review of medical records and interview it was determined a restraint/ seclusion order was written as a PRN ( as needed) order. This had the potential to affect all patients served by this facility and did affect Patient Identifier(PI) # 2.

Findings include:

1. PI # 2 was admitted to the girls adolescent unit 9/8/11 with a primary Axis I diagnosis of Major Depressive Disorder, recurrent no Psychotic Features, generalized Anxiety Disorder. On 10/4/11 a change in diagnosis was entered as Schizoaffective Disorder.

The restraint seclusion order form dated 10/16/11 at 6:00 PM documented the patient was placed in 4 point restraints, the order was marked for 2 hours time limit. The narrative documentation documented at 8:00 PM- pt (patient) continues to verbalize SI (suicidal ideation). Continue in 4 pt (point) restraints. 8:15 PM Dr... notified, received order by phone to continue 4 point restraints x 2 hours or prn (as needed).

A restraint order can not be written as a prn order.

On 10/27/11 at 10:45 AM an interview was conducted with Employee Identifier # 3, the case manager. EI # 3 confirmed the order said prn.

Based on review of medical records, facility policy and procedures and information provided to staff on annual updates and interview it was determined in 3 of 6 patients restrained and records reviewed the facility failed to:

1. Follow the policy/ recommendations for time out and correction of errors in the medical record
2. Follow the use of 1:1 supervision with patients
3. Document appropriately where a patient was in time out and for how long and
4. Have an order for the use of seclusion.

This had the potential to affect all patients served by this facility and did affect Patient Identifier(PI) #1, 5 and 8.

Facility Instructions for providing 1/1 supervision as provided to the surveyor on 10/27/11 at 9:30 AM by Employee Identifer (EI) # 6, the counselor:

" 1. Patient must be within line of vision at all times except for bathroom and bath times.

2. When the patient needs to use the bathroom, check the shower and bathroom to assure that all safety regulations are being adhered to. After the patient enters, staff must be close enough to the door to hear any suspicious activity and be prepared to intervene if necessary.

4. Remember that 1/1 supervision is used only as required to maintain safety for the patient and/or the patients on the unit...

6. Your responsibility is to your 1/1 patient. Do not respond to codes or attempt to assist with the duties of other staff. Do not leave your post unless there is clearly a safety issue involved.

8. Be prepared to intervene immediately if the patient begins to engage in unsafe activities. Call for help if needed but do not allow the patient to get near enough to light fixtures or air conditioner units to obtain a cutting instrument.

9. Call for help immediately if the patient attempts to leave your eyesight. "

Annual update for staff provided to the surveyor 10/27/11 at 9:30 AM,

" Quiet Room Rules: NO Patient is allowed in quiet room unless they are in restraints, seclusion or have a staff member sitting directly with them. This is a fire hazard due to the possibility of someone being locked inside. Time outs may be completed in patient's room with staff member monitoring... After use of the quiet room nurses and tech's are responsible for cleaning the bed and replacing the sheet."

Additional 1: 1 Observation Guidelines,

" Staff member must stay within arms length of patient at all times.
Staff member must go to all activities with patient.
Patients should not be allowed to argue with other patients or staff, if argument arises remove patient from situation.
Patient should not be close enough to another patient to get into physical altercation that cannot be stopped by the 1:1 staff."

Facility Policy: Time Out

Purpose:
To provide a comprehensive behavioral modification plan utilizing natural and logical consequences for disruptive behavior.

Definitions:

Therapeutic Time Out: A brief time limited therapeutic intervention allowing a child direct 1:1 intervention with a professional staff member. Time-outs are designed to be age-specific and occur within the group setting.

Procedure:
Therapeutic Time Out
Only a professional staff member may place a child in a therapeutic time-out. Therapeutic time-outs are age specific/ time specific as follows:
1. 1 minute for each year of age. Example: 7 years of age equals 7 minutes of therapeutic time-out.

Time-outs are to be conducted within the group setting in an area of decreased stimuli. The professional staff member will inform the patient of the identified disruptive behavior and the length of time-out. Following completion of the time-out a professional staff member will process the patient's feelings/ behaviors and identify more effective ways of coping.

Facility Policy: Correction of Information in the Medical Record
Policy: The correction of errors in the medical record is of vital importance. The medical record is a legal document and as such, should never be altered. Any corrections made should not obscure the original information and should be authenticated by the staff making the correction.

Procedure:
1. Errors made while recording: Errors made while recording should be drawn through with one straight line, initialed by the person recording and followed immediately by the correction.

Patient findings:

1. PI # 1 was admitted to the children's unit 10/7/11 with a primary Axis I diagnosis of Major Depressive Disorder, Single Episode, Severe without Psychotic Features. An Axis III diagnosis of Head Lice and Burns to Right forearm.

The 10/7/11 nurses note documented at 3:50 PM, " Placed in time out for not following directions. Remains very hyper. 5:45 PM, Sent to room for time out."

There was no documentation of the amount of time the patient spent in time out or any process to help the patient cope.

The 10/9/11 nurses note documented, " Has been reminded multiple times to keep hands to self, has been placed in time out in room for 10 minutes. Refuses to stay in room, will not follow directions, is very defiant."

Ten minutes is 3 minutes above what is allowed at 1 minute per year as this patient is 7 years old.

The 10/14/11 nurses note documented at 1030 AM, "...Frequent redirection and time out x 1 this AM..."

The 10/14/11 nurses note documented at 7:45 PM, "... Given T.O. ( time out) in nursing station with 1:1 attention. Pt (patient) had melt down , sobbing, whining... escorted to room at 9:45 PM after others asleep."

The 10/15/11 nurses note documented at 12:00 noon, "Given time out when outside due to not sharing swing and became enraged required return to unit due to her inability to calm herself."

The 10/15/11 nurses note documented at 2:00 PM, "Returned to classroom, refusing to follow directions- given time outs x 5."

The 10/19/11 nurses note documented at 5:30 PM, "Pt in quiet room with RN (Registered Nurse) for 20 minutes."
There was no order for the patient to be in the quiet (seclusion) room in the medical record. The 20 minutes exceeds what is recommended for a 7 year old.

The 10/20/11 nurses note documented at 8:15 AM, " Pitching anger outburst, rolling in floor placed in seclusion with door locked to ofc( office?) with RN till pt able to calm herself p (after) 12 minutes, got up in chair started asking questions."
There was no order for the patient to be in the quiet (seclusion) room in the medical record. The 12 minutes exceeds what is recommended for a 7 year old.

The 10/21/11 nurses note documented at 4:30 PM, " Being very disruptive on unit, not following directions. Defiant with staff. Placed in time out."
There was no documentation of the amount of time the patient spent in time out or any process to help the patient cope.

The 10/21/11 nurses note documented at 5:20 PM, " Being intrusive with peers and disruptive, placed in time out. Continues to be defiant with staff. Will not keep hands off other peers, placed in quiet room for time out."

There was no documentation of the amount of time the patient spent in time out, if this was a continued time out, if the patient was moved from one area to the quiet room or any contact with the physician.

The 10/22/11 nurses note documented at 2:00 PM, " Has been placed in time out numerous times today."

The 10/22/11 nurses note documented at 5:00 PM, " Placed in time out for not following directions, arguing with staff."

The 10/22/11 nurses note documented at 5:30 PM, " Continues to be disruptive, calling peers ugly names, showing them the bird fingers, have redirected multiple times and placed in time out today. After this episode pt was given an assignment."

There was no documentation of the amount of time the patient spent in time out or any process to help the patient cope.

The 10/23/11 nurses note documented at 5:30 PM, "... not following directions have placed pt in time out in the corner..."

In an interview on 10/27/11 at 10:35 AM with EI # 3, the RN Case Manager stated that the nurse should have written and order for 10/20/11 when taken to the seclusion room and the paperwork should have been completed.




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2. PI # 5 was admitted to the facility on 10/19/11 with diagnoses including Psychotic and History of Closed Head Injury.

Review of the nurse note dated 10/20/11 at 10:15 PM revealed the patient was lying in room on bed introducing fingers into anus then licking the fingers. The patient was then escorted to the quiet room per staff. Further review of the record revealed no documentation of a physician's order for the quiet room/seclusion.

The surveyor requested the order for seclusion on 11/4/11 in a written request. The response was there was no order for seclusion.

3. PI # 8 was admitted to the facility on 9/21/11 with diagnoses including Bipolar and Impulsive.

Review of the Nursing Reassessment dated 9/25/11 for 7:00 AM to 7:00 PM revealed no documentation of a Mental Status Exam.

Review of the Fifteen Minute Hall Check dated 9/26/11 for 6:00 to 6:30 PM revealed the patient was in the shower. Review of the Restraint/ Seclusion Protocol MD Order dated 9/26/11 at 6:25 PM revealed documentation at 6:25 PM the patient was agitated cursing staff and refusing to leave the nurse station. The patient was also going into peers rooms and the staff was unable to redirect the patient. The patient was escorted into the seclusion room and required 4 point restraints. The Fifteen Minute Hall Check and the Restraint/ Seclusion Protocol MD Order did not match.

Further review of the Fifteen Minute Hall Check dated 9/26/11 revealed documentation under level which was scratched through obliterating the documentation. There was no line through indicating an error in documentation.

Review of the Direct Supervision Observation Sheet dated 9/27/11 to 9/28/11 revealed documentation under 5:45 AM which was scratched through obliterating the documentation and caused inability to read entry. There was no line through indicating an error in documentation.

Review of the Direct Supervision Observation Sheet dated 9/28/11 to 9/29/11 revealed documentation on the side of the form which was scratched through obliterating the documentation. There was no line through indicating an error in documentation.

Review of the Direct Supervision Observation Sheet 2 which was dated 9/30/11 to 10/1/11 and none for 10/1/11 to 10/2/11.

Review of the Direct Supervision Observation Sheet dated 10/2/11 to 10/3/11 revealed documentation under 7:00 to 7:30 PM which was scratched through obliterating the documentation and caused inability to read entry. There was no line through indicating an error in documentation.

Review of the Direct Supervision Observation Sheet dated 10/3/11 to 10/4/11 revealed doodling all long the edge of the form.

Review of the Routine Physician Orders dated 10/5/11 at 8:40 AM revealed orders to discontinue 1:1 observation. Review of the Routine Physician Orders dated 10/5/11 at 3:40 PM revealed orders to resume 1:1 observation. Review of the Direct Supervision Observation Sheets revealed no documentation of an Observation form for 10/5/11.

Review of the Nursing Reassessment dated 10/5/11 at 4:45 PM stated the MD was called and 1:1 observation was resumed. This did not reflect the order documented on 10/5/11 at 3:40 PM as stated above.

Further review of the Nursing Assessment dated 10/5/11 revealed the patient was at the desk to keep safe yet patient had been placed on 1:1 for observation at either 3:40 PM or 4:40 PM. There was no documentation of the Direct Supervision Observation Sheet for 10/5/11 to refer to the 1:1 personnel who was assigned to this patient.

Further review of the Nursing Assessment dated 10/5/11 revealed the patient went into a peers room and hit the peer. There was no documentation the patient was on 1:1 observation. An interview was conducted with EI # 4 on 10/27/11 at 11:20 AM, who verified this episode should not have happened with a patient on 1:1 observation.

Further review of the Nursing Reassessment dated 10/5/11 revealed documentation at 6:55 PM of the patient being escorted to the Quiet Room. There was no documentation of a Restrain/Seclusion MD order for 10/5/11 at 6:55 PM.

Review of the Nursing Reassessment note dated 10/6/11 at 11:00 revealed the patient was escorted to the Quiet Room. Review of the Direct Supervision Observation Sheet dated 10/6/11 at 11:00 to 11:30 revealed documentation the patient was in his/her room.

Review of the Direct Supervision Observation Sheets revealed no documentation of a form for 10/7/11 or 10/8/11. The surveyor requested the above forms on 10/27/11 from EI # 4 and none could be provided prior to the survey exit.

Review of the physician orders dated 10/7/11 at 9:10 AM revealed an order for an Orthopedic Consult. The surveyor requested the consult on 10/27/11 from EI # 4 and none could be provided.

Based on observation, interviews and review of the facility's policy, it was determined the facility failed to ensure the nursing and pharmacy department kept an accurate record for controlled drugs. This had the potential to affect all patients and did affect Patient Identifier (PI) # 9 and # 7.

Findings include:

Facility Policy: Home Medications, Administration of # MM.012

Procedure:

2. Admission Nurse - Class II - IV drugs will be sent home with the family and NOT administered by the nurse caring for the patient.

An initial tour was conducted on 10/25/11 at 8:15 AM on the ICU (intensive care)/ adult unit. The surveyor went to the medication room, with Employee Identifer # 8, the charge nurse for the ICU, to conduct a narcotic count. EI # 8 opened the narcotic box and began counting controlled drugs that were in a patient's home medication bottle.

Patient Identifier (PI) # 9 had a home medication bottle which contained Alprazolam 1 mg (milligram) 5 1/2 tablets. There was no documentation of a Controlled Substance Log for this medication. The surveyor asked where this patient was and the response was, "discharged yesterday."


Patient Identifier (PI) # 7's had a blister pack of Oxycodone 2 tablets in each blister which equaled 5 mg (milligrams) per blister. There was no documentation of a Controlled Substance Log for this medication. The surveyor asked where this patient was and the response was, "discharged yesterday."



The surveyor asked EI # 8 where the Controlled Substance Logs were for the above controlled drugs. The response was, "at the pharmacy". The surveyor then asked was the Controlled Substance Log and the medication suppose to be separated and the response was, "no".

An interview was conducted on 10/25/11 at 12:30 PM with EI # 9, the Pharmacist. The surveyor requested the Controlled Substance Logs for the above controlled drugs. EI # 9 then obtained the logs. The surveyor asked if the controlled drugs and the Controlled Substance Logs should be separated and the response was, "no". The surveyor asked EI # 9 what the process was when the controlled drugs and the Controlled Substance Logs were separated and EI # 9 stated that the pharmacist would go to the floor and obtain the medication. The surveyor asked about the medications that belonged to patients. EI # 9 stated the patient's were to be given the home medication back when they left the Hospital. The surveyor then informed EI # 9 the controlled drug was still upstairs without any accountability.

A second tour of the ICU medication room was conducted on 10/25/11 at 12:40 with EI #9. The surveyor and EI # 9 went to enter the medication room and the door was not locked. Upon entering the medication room the surveyor and EI # 9 noted the keys were in the narcotic box unsupervised. EI # 9 stated this was unacceptable.

Based on review of medical records, review of policy and procedures and interview with Employee Identifier (EI) # 3, the Nurse Manager, it was determined in 5 of 7 open records reviewed the treatment team failed to update or change the goals, both short term and long term, and failed to update the interventions to meet the goals in the acute care setting. This affected Patient Identifier (PI) # 1, # 2, # 3, # 4 and # 8 and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Master Treatment Plan

Policy: To provide a comprehensive individualized and multidisciplinary plan of treatment for each patient.

Procedure:

1. The Master Treatment Plan (MTP) problem list will be initiated for each patient upon admission by the RN (Registered Nurse) on the unit per physician assessment.

2. Upon completion of patient assessment, the RN on the unit will initiate the objectives and modalities of treatment and complete within 24 hours.

4. The MTP will be completed and reviewed/revised by the treatment team according to the following schedule:
- completed within 5 days of admission
- reviewed every seven days of each patient's admission until discharge for each patient.

Instructions for completing MTP:

Discharge Goal: This is a measurable, specific goal for discharge identified for each problem listed.

Date: This is the date that the team member identified the short term goal for each identified problem.

Goal: This is the number for each short term goal listed.

Short term goal stated in behavioral terms: A short term goal describes incremental steps that the patient must achieve in order to reach the discharge criteria identified upon admission and/or during treatment team meetings. These are not objectives for the staff, but for the patient. Short term goals are written in a language that describes the patient's observable behavior in a measurable way.

Plan (Modality/ Frequency/ Approach);

Treatment plan or modalities are specific services, treatments, or therapy that the patient will receive or participate in. These interventions are the actions and approaches to be taken by staff in assisting the patient in obtaining the short term goals and working toward resolutions of the identified problem. This plan must include how often one will do the specific intervention.

Target date:
The staff and patient's estimate of when the short term goal will be achieved.

Date Resolved/ Deferred:

This is the date upon which the stated short term goal has been reached or deferred to outpatient care. This should be filled out during treatment team meetings but can be revised during the patient's course of treatment.


Patient findings:

1. PI # 1 was admitted to the children's unit 10/7/11 with a primary Axis I diagnosis of Major Depressive Disorder, Single Episode, Severe without Psychotic Features. An Axis III diagnosis of Head Lice and Burns to Right forearm.

The Master Treatment Plan was dated 10/7/11 with the following information:

Goal # 1- short term objectives-... will exhibit mood stabilization AEB (as evidenced by) no SI/HI (suicidal ideations/ homicidal ideations), no SIB (suicidal ideations behaviors), processing through family stressors and PTSD (post traumatic stess disorder), med (medication) and therapy compliance.

Interventions : 1. MD ( medical doctor) will RX( prescribe) with mood stabilizing meds to alleviate distress and see daily to evaluate response.
Target dates listed 10/21/11, 10/25/11 and 11/7/11. There was no documentation of any change being made to the interventions for Goal # 1 from 10/7/11 when it was identified through the patient's discharge 10/27/11.

Goal # 3 - short term objectives- pt (patient) will improve her impulse control AEB earning blue level 5 out of 7 days a week.

Interventions: 1. Identify impulsive behaviors, review the 'Stop light' technique, review scenarios in therapy and comply with medication management. Individual therapy (IT) 3 times a week and Group therapy (GT) 5 times a week.

Target dates listed 10/21/11, 10/25/11 and 11/7/11. There was no documentation of any change being made to the interventions for Goal # 3 from 10/7/11 when it was identified through the patient's discharge 10/27/11.

Goal # 4 - short term objectives- pt (patient) will exhibit a stable mood AEB (as evidenced by) earning blue level 5 to 7 days a week.

Interventions: 1... will develop positive coping skills, encourage venting during therapy, identify stressors and manage medication. Individual therapy 3 times a week and Group therapy 5 times a week.

Target dates listed 10/21/11, 10/25/11 and 11/7/11. There was no documentation of any change being made to the interventions for Goal # 3 from 10/7/11 when it was identified through the patient's discharge 10/27/11.

The patient was placed in time out 10/7/11, 10/9/11, 10/14/11 documented times two, 10/15/11 documented times two, 10/19/11, 10/20/11, 10/21/11 documented times two and 10/22/11 documented times 3.

Additional times outs were covered in the following documentation to show continued problems with no changes made to the interventions for the patient's care.

The 10/15/11 nurses note documented at 2:00 PM, "Returned to classroom, refusing to follow directions- given time outs x 5."

The 10/22/11 nurses note documented at 2:00 PM, " Has been placed in time out numerous times today."

Goal # 8 - short term objectives- pt (patient) will remain free of infection R/T (related to) burn on arm while receiving tx (treatment) at MVH (Mountain View Hospital) .

Interventions: 1. Nurse will monitor for S/S (signs and symptoms) of infection Q (each) shift. 2. Nurse will report any abnormal findings to MD (medical doctor) as needed. .3 Nurse will administer any treatment or medications ordered by MD, using 5 pt (point) rights.

Target dates listed 10/20/11 and 10/25/11. The 10/25/11 was marked through and resolved, well healing as of 10/21/11. There was no documentation regarding the burns, care provided or description of the burns from admission on 10/7/11 and the following nurse notes dated 10/9/11, 10/14/11, 10/15/11, 10/19/11, 10/20/11 or 10/21/11.

The treatment plan update dated 10/11/11 documented for Goal # 1- minimal progress-... continues to be somewhat impulsive, some defiance and verbal aggression noted. Increased interaction with peers.

The treatment plan update dated 10/11/11 documented for Goal # 3- minimal progress-...has earned blue level 3 days.

The treatment plan update dated 10/11/11 documented for Goal # 4- minimal progress-... does not talk during 1:1 but she will.

The treatment plan update dated 10/11/11 documented for Goal # 8- moderate progress-burn to forearm healing well.

There was no change to any of the interventions even though the patient continued to require frequent time outs to control her behaviors according to the nurse notes.

The treatment plan update was not signed by the psychiatrist or therapeutic educator on 10/11/11.

The treatment plan update dated 10/18/11 documented for Goal # 1- moderate progress-... continues to be hyper at times but slowly redirectable, no nightmares reported.

The treatment plan update dated 10/18/11 documented for Goal # 3- no progress marked-...has made blue level 4 days but her actions include NFD (not following directions), refusing assignments.

The treatment plan update dated 10/18/11 documented for Goal # 4- minimal progress- mood ... has made blue level 4 days, but has exhibited mood changes bit a peer 10/15/11..

The treatment plan update dated 10/18/11 documented for Goal # 8- marked progress- infection resolved, wound is healed with slight discoloration no S/S of infection no drainage.

There was no change to any of the interventions even though the patient continued to require frequent time outs to control her behaviors according to the nurse notes.

The treatment plan update was not signed by the psychiatrist on 10/18/11.

The treatment team failed to update or change the goals, both short term and long term, and failed to update the interventions to meet the needs of this patient who continued to require time outs through 10/22/11.

2. PI # 2 was admitted to the girls adolescent unit 9/8/11 with a primary Axis I diagnosis of Major Depressive Disorder, recurrent no Psychotic Features, generalized Anxiety Disorder. On 10/4/11 a change in diagnosis was entered as Schizoaffective Disorder.

The Master Treatment Plan was dated 9/8/11 with the following information:

Goal # 1- short term objectives-... peers and staff will remain free from harm at MVH.

Interventions : 1. Conduct B and B ( belongings and body) search on admit and prn (as needed). 2. Safety checks q (every) 15 minutes and prn (as needed). 3. Pt to read and sign' No harm contract' 4. Instruct pt on +( positive) coping skills. 5. Administer meds per MD/RN (registered nurse) and monitor effectiveness. 6. Notify MD of changes.

Target dates listed 9/16/11, 9/20/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11. There was no documentation of any change being made to the interventions for Goal # 1 from 9/8/11 when it was identified through the survey date 10/28/11.

Goal # 7- short term objectives-... will attend class daily and exhibit appropriate behavior AEB earning blue level 4-5 days.

Interventions : 1. Review appropriate behavior, encourage active participation, give positive feedback.

Target dates listed 9/30/11, 10/12/11, 10/18/11 and 10/25/11.

Goal # 8- short term objectives-... will work to decrease thoughts of negative traits AEB listing positive traits.

Interventions : 1... will list daily one positive statement about herself and on a chart or journal and process with therapist IT x 3/ GT x 10 weekly.

Target dates listed 9/24/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11.

Goal # 9- short term objectives-... will verbally identify if possible the source of depressed mood AEB listing things which cause depression.

Interventions : 1. Therapist will process with ... causes of depression IT x 3 /GT x 10 weekly.

Target dates listed 9/24/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11.

Goal # 10- short term objectives-... will exhibit mood stabilization AEB no SI and decreased depression med and therapy compliance learning positive coping skills and using them when dealing with depression.


Interventions : 1. MD will RX with mood stabilizing meds to alleviate distress and see daily to evaluate response.

Target dates listed 9/24/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11.

The last documented medication change on the treatment plan was 10/9/11- Depakote ER (extended release) 100 mg (milligrams) po (by mouth) now then HS (hour of sleep) starting 10/10/11. Mood swings.

The treatment plan update dated 9/13/11 documented for Goal # 1-minimal progress, continues to have SI, blocking noted with inappropriate behaviors.

The treatment plan update dated 9/13/11 documented for Goal # 7-minimal progress, participates minimally but with little motivation.

The treatment plan update dated 9/13/11 documented for Goal # 8-minimal progress, has a hard time listing positive traits.

The treatment plan update dated 9/13/11 documented for Goal # 9-moderate progress, denies being depressed.

The treatment plan update dated 9/13/11 documented for Goal # 10-no progress, continues to have SI, laughs inappropriately and minimizes behaviors.

The treatment plan update dated 9/20/11 documented for Goal # 1-minimal progress, continues to voice harmful thoughts.

The treatment plan update dated 9/20/11 documented for Goal # 7-minimal progress, seems to have little concern for education.

The treatment plan update dated 9/20/11 documented for Goal # 8-no progress, is working to decrease negative thoughts.

The treatment plan update dated 9/20/11 documented for Goal # 9-minimal progress, has discussed with her therapist her depression and included one incident of a friend committing suicide.

The treatment plan update dated 9/20/11 documented for Goal # 10-no progress, continues to have suicidal thoughts, she is now 1:1 observation for safety.

The treatment plan update dated 9/27/11 documented for Goal # 1-regression, pt still suicidal and attempts to harm self.

The treatment plan update dated 9/27/11 documented for Goal # 7-no progress, continues to have no participation.

The treatment plan update dated 9/27/11 documented for Goal # 8-regression, has not decreased her negative thoughts.

The treatment plan update dated 9/27/11 documented for Goal # 9-no progress, has listed sources of her depression but suicidal thoughts continue.

The treatment plan update dated 9/27/11 documented for Goal # 10- regression, no comments documented.

The therapist notes on the form documented, "She has attempted suicide, she continues to have SI."

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

The treatment plan update dated 10/4/11 documented for Goal # 1-regression, pt still suicidal and attempts to harm self.

The treatment plan update dated 10/4/11 documented for Goal # 7-no progress, is not attending class.

The treatment plan update dated 10/4/11 documented for Goal # 8-minimal progress, has listed some positive traits but does not reflect often.

The treatment plan update dated 10/4/11 documented for Goal # 9-no progress, has not identified every source of her depression.

The treatment plan update dated 10/4/11 documented for Goal # 10-no progress, continues suicidal with attempts- continues 1:1 for safety.

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

The treatment plan update dated 10/11/11 documented for Goal # 1-regression, pt still suicidal and attempts to harm self.

The treatment plan update dated 10/11/11 documented for Goal # 7-no progress, is not attending class.

The treatment plan update dated 10/11/11 documented for Goal # 8-regression, negative thoughts and comments continue.

The treatment plan update dated 10/11/11 documented for Goal # 9-regression, has attempted to harm herself, restrained for safety.

The treatment plan update dated 10/11/11 documented for Goal # 10-no progress, has had multiple restraints R/T SI ( related to suicidal ideations).

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

The treatment plan update dated 10/18/11 documented for Goal # 1-regression, still makes attempts to hang or choke self, continues 1:1 observation and SI thoughts.

The treatment plan update dated 10/18/11 documented for Goal # 7-no progress.

The treatment plan update dated 10/18/11 documented for Goal # 8-no progress, continues to make negative comments about herself.

The treatment plan update dated 10/18/11 documented for Goal # 9-regression, denies depression at times and she has attempted suicide requiring restraining.

The treatment plan update dated 10/18/11 documented for Goal # 10-no progress, continues with SI/HI (suicidal/homicidal) voiced- several attempts noted choking, placing head under water in sink.

The therapeutic educator and activity therapist did not sign attendance at the treatment team 10/18/11.

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

In an interview on 10/27/11 at 10:45 AM with EI # 3, nurse manager, it was confirmed that there was no documented update or change to the treatment plan interventions or goals.

3. PI # 3 was admitted to the girls adolescent unit 7/14/11 with a primary Axis I diagnosis of Bipolar Disorder not otherwise specified,
Impulse Control Disorder, and Conduct Disorder.

The Master Treatment Plan was dated 7/14/11 with the following information:

Goal # 1- short term objectives- will exhibit mood stabilization AEB decreased anger outburst no assaultive behaviors, no SI/HI/AVH (suicidal ideation/ homicidal ideation/auditory visual hallucinations), med compliance and therapy compliance.

Interventions: 1. MD will rx (prescribe) mood stabilizing meds to alleviate distress and see daily to evaluate response.

Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.


Goal # 2 - short term objectives-... will be free of any physical aggression and anger AEB 5 consecutive days free of any outburst.

Interventions : 1... and therapist will identify triggers to neg (negative) behavior and develop coping skills to deal with triggers. IT x 3; GT x 10 ( individual therapy 3 times a week and group therapy 10 times a week)


Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.

Goal # 3 - short term objectives-... will attend class daily and exhibit appropriate behavior AEB earning blue level 4/5 days.

Interventions : 1. Review appropriate behavior, encourage active participation give positive feedback.

Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.

Goal # 6 - short term objectives- pt will be free from harm while at MVH.

Interventions : 1. Search pt and belonging and remove all harmful's. 2. Give meds as ordered by MD. 3. Monitor for safety and changes in mood/ affect. 4. Give pt 1:1 when agitated to vent frustrations.

Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.

The treatment plan update dated 10/4/11 documented for Goal # 1-moderate progress continues to have frequent outburst and aggression.

The treatment plan update dated 10/4/11 documented for Goal # 2-minimal progress, has exhibited improved anger aggression towards peers but has exhibited self-injurious behavior.

The treatment plan update dated 10/4/11 documented for Goal # 3-no progress, continues to be uncooperative...

The treatment plan update dated 10/4/11 documented for Goal # 6- moderate progress, pt has scratched superficial scratches on self no other problems noted.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed no progress to moderate progress 10/4/11.

The treatment plan update dated 10/11/11 documented for Goal # 1-regression,has exhibited more physical aggression- she has attacked multiple staff members in 2 days.

The treatment plan update dated 10/11/11 documented for Goal # 2-regression, has exhibited anger/aggression towards self and staff.

The treatment plan update dated 10/11/11 documented for Goal # 3-regression, continues to be uncooperative in class and is increasing aggression toward staff and peers.

The treatment plan update dated 10/11/11 documented for Goal # 6- regression, pt has made attempts to scratch self and cause self harm and has needed to be restrained.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression in each of the goals on 10/11/11.

The treatment plan update dated 10/18/11 documented for Goal # 1-minimal progress, continues to have mood swings, days of physical verbal aggression noted.

The treatment plan update dated 10/18/11 documented for Goal # 2-regression, has fought with peer and required restraints.

The treatment plan update dated 10/13/11 documented for Goal # 3-minimal progress, has had some increase in participation and has had a couple of days of improved behavior.

The treatment plan update dated 10/18/11 documented for Goal # 6- there was no documentation related to this goal.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression and minimal progress in each of the goals on 10/18/11.

4. PI # 4 was admitted to boys adolescent unit 10/3/11 with a primary Axis I diagnosis of Bipolar Disorder and Impulse Control Disorder.

The Master Treatment Plan was dated 10/4/11 with the following information:

Goal # 1- short term objectives- will exhibit mood stabilization AEB no SI/HI and decreased mood swings, no verbal/physical aggression, processing through family stressors and conflicts, med and therapy compliance.

Interventions: 1. MD will rx (prescribe) mood stabilizing meds to alleviate distress and see daily to evaluate response.

Target dates listed 10/14/11 and 10/25/11.

Goal # 2- short term objectives- will attend class daily and exhibit appropriate behavior AEB being blue level 4/5 days.

Interventions: 1. Review appropriate behavior, encourage active participation, give positive feedback.

The target date could not be read on this entry.

Goal # 3- short term objectives- will decrease anger outburst AEB remaining on blue 4/5 days

Interventions: 1. will discuss triggers for anger, anger both positive and negative coping skills, use talk therapy and comply with med management IT X 3/ GT x 10/wk.

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

Goal # 4- short term objectives- will decrease impulsive behavior AEB remaining on blue 4/5 days

Intervention: 1. will review triggers that lead to impulsive behavior positive and negative coping skill review step management technique, talk therapy and comply with med management IT X 3/ GT x 10/wk.

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

Goal # 5- short term objectives- will deny any SI AEB reporting no SI daily

Intervention : 1. will identify triggers for SI, develop safety plan use talk therapy, deep breathing techniques positive and negative coping skills IT X 3/ GT x 10/wk

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

Goal # 6- short term objectives- pt, staff, peers will be free of harm while at MVH

Intervention : 1. orient pt to staff, peers unit rules. 2. B/B (belongings/ body) search on admit and prn 3. administer meds as ordered 4. contact MD for changes in behavior, mood 5. 1:1 with pt each shift to ID (identify) and enhance coping skills 6. every 15 minute safety checks.

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

The treatment plan update dated 10/4/11 documented for Goal # 1-no progress continues to be defiant, verbally aggressive.

The treatment plan update dated 10/4/11 documented for Goal # 2-no progress, has had insufficient time to fully participate.

The treatment plan update dated 10/4/11 documented for Goal # 3-no progress, will work on learning coping skills to decrease his anger

The treatment plan update dated 10/4/11 documented for Goal # 4- no progress, will work on decreasing impulsive behavior by using stop light technique.

The treatment plan update dated 10/4/11 documented for Goal # 5-no progress, will develop safety plan and work on decreasing SI.

The treatment plan update dated 10/4/11 documented for Goal # 6-no progress, staff here remain free from harm since admission.

The treatment plan update dated 10/11/11 documented for Goal # 1-no progress continues to have physical and verbal aggression, no insight, minimizing behavior.

The treatment plan update dated 10/11/11 documented for Goal # 2-regression, is mostly uncooperative and is frequently defiant and disrespectful.

The treatment plan update dated 10/11/11 documented for Goal # 3-no progress, has numerous anger outburst daily.

The treatment plan update dated 10/11/11 documented for Goal # 4- no progress- has not displayed use of positive coping skills to decrease impulses.

The treatment plan update dated 10/11/11 documented for Goal # 5-moderate progress, denies any SI.

The treatment plan update dated 10/11/11 documented for Goal # 6-minimal progress, has remained free from harm as have staff since admission.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/11/11.

The treatment plan update dated 10/18/11 documented for Goal # 1-regression, no comments were written on the form.

The treatment plan update dated 10/18/11 documented for Goal # 2-minimal progress, has frequent outbursts of profanity and threat in days but has participated in class today (10/18/11).

The treatment plan update dated 10/18/11 documented for Goal # 3-minimal progress, displays numerous outburst weekly.

The treatment plan update dated 10/18/11 documented for Goal # 4- minimal progress-displays minimal use of positive coping skills to decrease impulsive behaviors.

The treatment plan update dated 10/18/11 documented for Goal # 5-minimal progress, still has thoughts of SI with no plan.

The treatment plan update dated 10/18/11 documented for Goal # 6-no progress, pt continues to have outburst with staff and peers, pt exhibits decreased frustrations and will hit wall when angry.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/18/11.

The 10/18/11 treatment plan update was not signed by the psychiatrist.

PI # 4 was transferred to the adult unit 10/21/11 at 12:00 noon for safety due to anger control problems.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 1-regression, no comments were written on the form.

The treatment plan update dated 10/18/11 documented for Goal # 2-minimal progress, has frequent outbursts of profanity and threat in days but has participated in class today (10/18/11).

The treatment plan update dated 10/18/11 documented for Goal # 3-minimal progress, displays numerous outburst weekly.

The treatment plan update dated 10/18/11 documented for Goal # 4- minimal progress-displays minimal use of positive coping skills to decrease impulsive behaviors.

The treatment plan update dated 10/18/11 documented for Goal # 5-minimal progress, still has thoughts of SI with no plan.

The treatment plan update dated 10/18/11 documented for Goal # 6-no progress, pt continues to have outburst with staff and peers, pt exhibits decreased frustrations and will hit wall when angry.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/18/11.

The 10/18/11 treatment plan update was not signed by the psychiatrist.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 1-regression, no comments were written on the form.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 2-no progress, participates in class occasionally but has frequent outburst and aggression.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 3-minimal progress, rarely uses positive coping skills to decrease anger outburst, multiple outburst with property destruction weekly.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 4- minimal progress- impulsive rarely uses positive coping skills to decrease his impulsive behaviors.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 5-moderate progress, had thoughts of SI since last update but denies any as of yesterday.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 6- no information.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/25/11.

The 10/25/11 treatment plan update was not signed by the psychiatrist, therapeutic educator or staff nurse. The discharge plan was documented for 10/26/11 to discharge to another facility.

In an interview on 10/28/11 at 11:00 AM with EI # 3 regarding changes to the treatment plan. EI # 3 responsed, that they knew they needed to work on these areas. Employee Identifier # 5, Director of Clinical Services on 11/2/11 returned the following information about the updating the treatment plan. EI # 5's written response was,"No change was made to treatment plan prior to move to ICU ( adult intensive care unit). Move to ICU was change to his plan. Once on ICU his behaviors improved greatly."


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5. PI # 8 was admitted to the facility on 9/21/11 with diagnoses including Bipolar and Impulsive.

Review of the Treatment Plan dated 9/21/11 revealed Goal # 1 was for the patient to be free from harm for up to seventy-two hours prior to discharge.

Interventions include:

A. Initiate no harm contract.

B. Complete body and belonging search on admission and as needed.

C. Perform fifteen minute safety checks.

D. Administer meds as ordered.

E. Notify MD of Changes.

Review of the Team Plan Update dated 9/27/11 revealed a team review of the goals and interventions.

Review of the Restrain/Seclusion Protocol MD Order dated 9/26/11 at 4:30 PM revealed the patient began banging head on the window and on the walls.

Review of the Restrain/Seclusion Protocol MD Order dated 9/26/11 at 6:25 PM revealed the patient began banging head on the walls.

Review of the Restrain/Seclusion Protocol MD Order dated 9/27/11 at 8:25 AM revealed the patient began banging head on the walls and attempting to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 9/29/11 at 8:00 AM revealed the patient was touching the staff and peers without permission. The patient became combative and attempted to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 9/30/11 at 8:00 AM revealed the patient attempted to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 9/30/11 at 2:25 PM revealed the patient began hitting at and attempting to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/2/11 at 7:45 PM revealed the patient began banging head on the walls.

Review of the Team Plan Update dated 10/4/11 revealed a team review of the goals and interventions with only minimal progress toward goal. There was no documentation in a change in the interventions to help with the potential harm.

Review of the Restrain/Seclusion Protocol MD Order dated 10/5/11 at 8:25 PM revealed the patient began banging head on the walls and biting self.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 11:00 revealed the patient wrapped shirt around neck and attempted to bite staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 3:00 PM revealed the patient attempted to hit and bite staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 3:40 PM revealed the patient attempted to hit, kick and bite staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 5:20 PM revealed the patient attempted to hit and bite staff.

Review of the physician's order dated 10/6/11 at 5:30 PM revealed orders to transfer the patient to the ICU Unit.

Review of the Team Plan Update dated 10/11/11 revealed a team review of the goals and interventions with no documentation of progress toward goal. There was no documentation in a change in the interventions to help with the potential harm even though the patient was transferred to the ICU Unit.

There was no documented need for restraint/seclusion until 10/11/11. Review of the Restrain/Seclusion Protocol MD Order dated 10/11/11 at 2:35 PM revealed the patient began banging head on wall and threaten peers.

Review of the Restrain/Seclusion Protocol MD Order dated 10/14/11 at 5:15 AM revealed the patient began assaulting staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/17/11 at 11:40 AM revealed the patient head butted a staff member.

Review of the Team Plan Update dated 10/18/11 revealed a team review of the goals and interventions with no documentation of progress toward goal. There was no documentation in a change in the interventions to help with the potential harm.

The target dates on the original Treatment Plan for goal # 1 were changed from 9/28/11, 10/11/11, 10/20/11, and 10/25/11. There was no documentation the team reviewed the interventions to help improve potential harm.

An interview with EI # 4, a Nurse Manager, on 10/27/11 at 11:20 AM verified there was no documentation the team reviewed and updated the interventions.