HospitalInspections.org

Based on interview and review of the facility's Quality Assurance and Performance Improvement Program (QAPI), it was determined that the hospital's governing body did not indicate specific details of data collection.

Findings include:

On 4/13/15 and 4/14/15, the facility's QAPI for 2015 was reviewed. There was no documentation found in the QAPI that specified what projects needed to be implemented nor what data needed to be collected. While there were many audits pertaining to patient care and medical records, there was no prioritizing nor organization of the information.

On 4/13/15 and 4/14/15, the Administrator and the Director of Nursing were interviewed. When they were asked about specific QAPI projects and data collection pertaining to these projects, they expressed that they were unsure of the expectation of the QAPI regulations and they asked many questions to help clarify what they needed to do.

Based on interview and review of the facility's Quality Assurance and Performance Improvement Program (QAPI), it was determined the hospital did not set priorities for its performance improvement activities.

Findings include:

A review of the facilities QAPI Program for 2015 revealed that the hospital did not set priorities for its performance improvement activities. For the activities selected there was no information as to the reasons why they were selected. There was no documentation that the hospital's governing body approved the quality performance improvement activities.

On 4/13/15 and 4/14/15, the Administrator and the Director of Nursing were interviewed. When they were asked about specific QAPI projects and data collection pertaining to these projects, they expressed that they were unsure of the expectation of the QAPI regulations and they asked many questions to help clarify what they needed to do.

Based on interview and review of the facility's Quality Assessment and Performance Improvement Program (QAPI) for 2015, it was determined that the facility did not conduct effective performance improvement projects.

Findings include:

A review of the facilities QAPI Program for 2015 revealed that the facility did not document what quality improvement projects needed to be conducted, the reasons for conducting these projects, how to conduct the projects and how to collect data.

On 4/13/15 and 4/14/15, the Administrator and the Director of Nursing were interviewed. When they were asked if the hospital's governing body had addressed priorities for improved quality of care and patient safety and if they had determined the number of distinct improvement projects needed they expressed that they were unsure of the expectation of the QAPI regulations and they asked many questions to help clarify what they needed to do.

Based on record review and interview, it was determined that the hospital's governing body did not ensure that the hospital's Quality Performance Improvement Program (QAPI) addressed priorities for improved quality of care and patient safety and that the determination of the number of distinct improvement projects was conducted annually.

Findings include:

A review of the facilities QAPI Program for 2015, revealed that the governing body did not document which quality improvement projects needed to be conducted, the reasons for conducting these projects, or how to conduct the projects and how to collect data. There was no documentation that the hospital's governing body approved the quality performance improvement activities. While there were many audits pertaining to patient care and medical records, there was no prioritizing nor organization of the information nor was there documentation that the governing body approved these activities.

07813

Based on record review, and interview, the facility failed to provide five (5) of five (5) active sample patients (A1, A2, A3, A4, A5, A6 and A8) with Master Treatment Plans (MTPs) that included physician and nursing interventions for identified psychiatric problems. These deficiencies result in failure to guide treatment staff in the provision of specific treatment for these patients.

Findings include:

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/9/15), A2 (update 4/9/15), A3 (update 4/9/15), A4 (update 4/9/15), and A5 (update 4/10/15), A6 (update 4/10/15) and A8 (4615).

B. Treatment Plan Findings:

1. Patient A1:

For identified problem, "Anger Management...angry behaviors - with injuries to others," there were no specific nursing interventions to direct nursing personnel in monitoring and care of this patient when presenting angry behaviors.

2. Patient A2:
For identified problems, "Psychotic Symptoms...manifested by Hallucinations - (Patient) reports experiencing command hallucination (sic) telling (him/her) to kill (his/her) 5 year old granddaughter" and "Depressed Mood...with complaints of feeling sad or empty," there were no nursing interventions to direct nursing personnel in the care of this patient in the clinical area.

3. Patient A3:
For identified problem, "Psychotic Symptoms ...manifested by: Disorganized Speech - manifested by loose associations that impairs (sic) normal communications - with incoherence to the point of 'word salad'," there were no identified nursing interventions.

4. Patient A4:
For identified problem, "Cognitive Impairment ...manifested by inattention and impulsivity...sexually inappropriate...forgets peoples' names, gets lost in familiar settings," there were no identified nursing interventions to direct nursing personnel in the care of this patient.

5. Patient A5:
a. For identified problem, "Psychotic Symptoms ...manifested by disorganized speech -manifested by tangentiality that impairs normal communications. Hallucinations- of pejorative or threatening voices," there were no specific nursing interventions to direct nursing personnel in caring for these presenting behaviors.

A nursing intervention to prevent aggressive behavior was inappropriately listed for this problem. It was stated as "Nurse will use...de-escalation techniques to help (Patient) regulate (his/her) own behaviors independently."

b. For identified problem, "Danger to self...Danger to others," the only nursing intervention was listed as "Nurse will monitor status and evaluation for continued need for chemical restraint..." There were no nursing interventions to address specific monitoring or preventive interventions for this patient.

6. Patient A6:
For identified problem, "Paranoid Process...manifested by Paranoid Delusion...auditory and visual hallucinations...," there were no identified physician interventions.

7. Patient A8:
For identified problems, "Depressed Mood..manifested by fatigue-clearly associated with mood. Feeling of worthlessness," and "Social Grief/Loss...experienced a series of life losses ...independence due to (his/her) Parkinson's...," there were no identified physician or nursing interventions.

C. Interview:

B. Interview:

1. On 4/14/15 at 11 a.m. the Medical Director acknowledged that there should have been physician interventions on the treatment plans for Patients A6 and A8.

2. During interview on 4/14/15 at 12:00 noon, the Director of Nursing acknowledged that there were no nursing interventions on the treatment plans to direct nursing personnel in the specific monitoring and preventions for patients' psychiatric/behavioral problems.

07813

Based on record and interview, the facility failed to provide MTPs that specified the name and discipline of staff responsible for implementing interventions for seven (7) of seven (7) active sample patients (A1, A2, A3, A4, A5, A6 and A8). Failure to assign specific staff members for intervention modalities results in an inability to determine what staff member is responsible for ensuring the implementation of interventions, potentially hampering the effective coordination of treatment modalities.

A. Record Review

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/9/15), A2 (update 4/9/15), A3 (update 4/9/15), A4 (update 4/9/15), and A5 (update 4/10/15), A6 (update 4/10/15) and A8 (4615). This review revealed that MTPs included the discipline, but failed to include the name of the specific clinical staff responsible for implementing interventions.

B. Interview:

During interview on 4/14/15 at 11:50 a.m. the Director of Social Work related that he was not aware that the staff person's name must be listed for each intervention, but thought that listing the responsible discipline was sufficient.

28209

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

A. Ensure that psychiatric evaluations included an inventory of patients' strengths which could be used in formulating treatment in the psychiatric evaluations for one (1) of seven (7) active sample patients (A2). Failure to identify patient strengths potentially impairs the psychiatrist's ability to choose treatment modalities which best utilize the patient's attributes in therapy. (Refer to 117)

B. Ensure that psychiatrist interventions were included in treatment plans for two (2) of seven (7) active sample patients (A6 and A8). (Refer to B122)

Based on interview, and record review, it was determined that the Director of Nursing failed
to ensure that treatment plans included individualized nursing interventions for six (6) of seven (7) active sample patients (A1, A2, A3, A4, A5 and A8). This failure prevented nursing personnel from providing safe, consistent focused treatment.

Findings include:

A. Record Review:

The MTPs for the following patients were reviewed (dates of plans in parentheses): A1 (4/9/15), A2 (update 4/9/15), A3 (update 4/9/15), A4 (update 4/9/15), and A5 (update 4/10/15), A6 (update 4/10/15) and A8 (4615).

B. Treatment Plan Findings:

1. Patient A1:
For identified problem, "Anger Management...angry behaviors - with injuries to others," there were no specific nursing interventions to direct nursing personnel in monitoring and care of this patient when presenting angry behaviors.

2. Patient A2:
For identified problems, "Psychotic Symptoms...manifested by Hallucinations - (Patient) reports experiencing command hallucination (sic) telling (him/her) to kill (his/her) 5 year old granddaughter" and "Depressed Mood...with complaints of feeling sad or empty," there were no nursing interventions to direct nursing personnel in the care of this patient in the clinical area.

3. Patient A3:
For identified problem, "Psychotic Symptoms ...manifested by: Disorganized Speech - manifested by loose associations that impairs (sic) normal communications - with incoherence to the point of 'word salad'," there were no identified nursing interventions.

4. Patient A4:
For identified problem, "Cognitive Impairment...manifested by inattention and impulsivity...sexually inappropriate...forgets peoples' names, gets lost in familiar settings," there were no identified nursing interventions to direct nursing personnel in the care of this patient.

5. Patient A5:
a. For identified problem, "Psychotic Symptoms...manifested by disorganized speech -manifested by tangentiality that impairs normal communications. Hallucinations- of pejorative or threatening voices," there were no specific nursing interventions to direct nursing personnel in the care of these presenting behaviors.

A nursing intervention to prevent aggressive behavior was inappropriately listed for this problem. It was stated as "Nurse will use...de-escalation techniques to help (Patient) regulate (his/her) own behaviors independently."

b. For identified problem, "Danger to self...Danger to others," the only nursing intervention was listed as "Nurse will monitor status and evaluation for continued need for chemical restraint..." There were no nursing interventions to address specific monitoring or preventive interventions for this patient.

6. Patient A8:
For identified problems, "Depressed Mood..manifested by fatigue-clearly associated with mood. Feeling of worthlessness," and "Social Grief/Loss...experienced a series of life losses...independence due to (his/her) Parkinson's...," there were no identified nursing interventions.

C. Interview:

During interview on 4/14/15 at 12:00 noon, the Director of Nursing acknowledged that there were no nursing interventions on the treatment plans to direct nursing personnel in the specific monitoring and preventions for patients' psychiatric/behavioral problems.