HospitalInspections.org

Based on interview, record review, and policy review the facility failed to develop nursing care plan goals and interventions when using high alert medications, and for medical issues of Deep Vein Thrombosis (DVT-blood clots), Degenerative disc disease (a condition in the spine that can cause pain), and Osteoarthritis (a condition that causes breakdown of joints that may include the knees, hips, spine and hands) for two patients (#1 and #2) of 13 patients with psychiatric and co-occurring medical problems. The facility also failed to develop a nutritional care plan to address the low body weight for one patient (#15). These failures had the potential to affect all psychiatric inpatients by failing to ensure that the patients' medical needs were met. The facility census was 77.

Findings included:

1. Review of the facility's policy titled, "Interdisciplinary Treatment Plan: Inpatient Units," showed:
- An individualized interdisciplinary treatment plan was initiated for each patient on admission.
- The treatment plan was based on assessments of the patient's clinical needs.
- The treatment plans included goals and objectives for treatment and prescribed clinical interventions.
- An individualized plan was developed for active patient problems.
- The treatment plan was reviewed at regular intervals and updated as needed.

2. Record review of Patient #1's Psychiatric Evaluation dated 06/11/15 showed the patient was admitted on 06/08/15 for psychotic symptoms and medication management.

Record review of a physician order dated 06/15/15 at 8:30 AM, showed a new order to start Clozaril (a medication for treatment-resistant schizophrenia (a major disorder of thought and perception) and reducing suicidal behavior. The order included the need to obtain a stat (immediate) Complete blood count (CBC, a blood test used to evaluate overall health) prior to administration of the medication and initiate vital signs twice daily.

Record review of the Medication Profile (a list of a patient's medications provided by the pharmacy for medication orders) showed that Clozaril was a "High Alert Medication," that required the following:
- Draw blood for a CBC before the medication was initiated and weekly thereafter.
- Report white blood counts (a measure of the body's ability to fight infection) less than 3500 (below normal results).
- Monitor for signs and symptoms of infection.

Record review of the Master Treatment Plan showed no goal or interventions for the physician's order for the initiation and management of the medication, Clozaril. Staff failed to document the patient's need for blood work and vital sign monitoring due to the potential for infection.

During an interview on 07/07/15 at 3:15 PM, Staff M, Registered Nurse (RN), stated that they do not document goals and interventions for Clozaril usage in the treatment plan.

3. Record review of Patient #2's History and Physical (H & P) dated 06/30/15, showed that the patient was admitted on 06/29/15 for suicidal thoughts and depression. Medical problems included the following:
- History of DVTs that required anticoagulant (medications that thin the blood) therapy.
- History of Degenerative disc disease that required pain management.
- Osteoarthritis that required pain management.

Record review of Patient #2's Nursing Assessment dated 06/29/15, showed that the patient had a history of severe pain, blood clots, and arthritis.

Record review of Patient #2's a physician order dated 06/29/15, showed that Morphine ER 60 mg every 12 hours (a narcotic pain medication) and Warfarin (a blood thinning medication) with dosages ordered for each day of the week.

Record review of Patient #2's Master Treatment Plan showed no goal or interventions for the problem of blood clots that required anticoagulant therapy; and degenerative disc disease and osteoarthritis that required pain management.

4. Record review of Patient #15's H & P dated 07/07/15, showed the patient was admitted on 07/06/15 with a diagnosis of being underweight.

Record review of the Nursing Admission Assessment dated 07/06/15, showed the patient had a poor appetite.

Record review of a Physician's Order dated 07/07/15, showed the physician ordered Boost twice daily.

Record review of the Master Treatment Plan, on 07/08/15 at 9:45 AM, showed no dietitian's nutritional plan for the patient. Staff failed to address the patient's low body weight and/or the provision of the Boost as recommended by the physician.


12450