HospitalInspections.org

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to follow their adopted policy related to assessing patient health status, care needs, and response following an intervention (Electro Convulsive Therapy) for four of six MRs reviewed (MR1, MR2, MR3 and MR6).

Findings include:

A review conducted on April 19, 2012, of facility policy, No. 640-031.2 "Electro-Convulsive Therapy," Effective Date: 2/22/11, revealed "Upon Return from Treatment: a. The RN will: 1. Assesses the patient upon return from ECT... 2. Ensure Vital signs are monitored immediately upon return to unit and repeat every 15 minutes until stable. Vital signs will be documented on the patient's vital sign record. 3 Continue monitoring the patient to ensure patient safety...."

A review conducted on April 19, 2012, of MR1, MR2, MR3 and MR6, revealed that the patients received ECT. There was no documentation that the patient's vital signs were monitored immediately upon return to the unit and every 15 minutes until stable.

An interview conducted with EMP4 and EMP5 on April 19, 2012, at 1:45 PM confirmed that there was no documentation that the patient's vital signs were monitored immediately upon return to the unit and every 15 minutes until stable.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined that Belmont Center for Comprehensive Treatment failed to ensure patient safety when reviewing medication orders to include all elements of an order : dose, strength, units, route, frequency and rate, as required for two of 10 open medical records (MR12 and MR13).

Findings include:

A review of facility policy "PRN Medication," dated March 15, 2012, revealed "Purpose: To establish guidelines for the safe, effective and appropriate use of PRN medications...Procedures: A. The physician will order PRN medication in appropriate dosage and safe intervals, in anticipation of or in response to the patient's complaint of symptoms of unexpected physical or emotional pain or discomfort that arise in the course of hospitalization..."

1) A review of MR12 and MR13, conducted on April 18, 2012, revealed pre-printed admission orders that provided a choice for route of administration of a medication. The physician did not order a specific route of administration for Diphenhydramine. It was ordered as "IM/po" (intramuscular or by mouth).

An interview was conducted with EMP2 on April 18, 2012, at approximately April 18, 2012, at 2:30 PM. EMP2 confirmed that MR12 and MR13, contained preprinted physician orders that do not specify the exact route ordered for the medication.

Based on observation tours and staff interview, it was determined that Belmont Center for Comprehensive Treatment failed to remove outdated supplies and products from patient use.

Findings include:

A request was made to EMP1 on April 19, 2012, at approximately 12:30 PM for a facility policy related to removing outdated supplies and products from patient use. EMP1 stated that the facility did not have a policy related to removing outdated supplies and products from patient use.

1) An observation on April 18, 2012, at approximately 1:30 PM of the One South Psychiatric Unit Medication Room revealed one 3M Steri Strip marked expired November 2010.

An interview conducted with EMP2 on April 18, 2012, at approximately 1:30 PM confirmed the above product was expired.

2) An observation on April 18, 2012, at approximately 1:40 PM of the One Center Psychiatric Unit Medication Room revealed the following expired supplies and products: 11 packets of sterile lubricating jelly marked expired January 2012; three 10 ml single dose 0.9% Sodium Chloride Inj. USP marked expired March 1, 2012; and two 3M Cavilon sterile no sting barrier film marked expired February 2012.

An interview with EMP2 on April 18, 2012, at approximately 1:40 PM confirmed the above supplies and product were expired.

3) An observation on April 18, 2012, at approximately 2:00 PM of the Two East Psychiatric Unit Medication Room revealed the following expired supplies and products: 100 Siemens multistix reagent strips for urinalysis marked expired September 2011; seven Ag/AGCl pregelled electrodes packages marked expired May 2008; 14 3M Steri Strips marked expired October 2010; and 11 3M Steri Strips marked expired November 2010.

An interview with EMP2 on April 18, 2012, at approximately 2:00 PM confirmed the above supplies and products were expired.

4) An observation on April 18, 2012, at approximately 2:20 PM of the Two Center Psychiatric Unit Medication Room revealed two BBL Culture Swabs packets marked expired August 2009.

An interview with EMP2 on April 18, 2012, at approximately 2:20 PM confirmed the above product was expired.

5) An observation on April 18, 2012, at approximately 2:30 PM of the Two South Psychiatric Unit Medication Room revealed 15 antiseptic cleansing wipe packets marked expired October 2010.

An interview with EMP2 on April 18, 2012, at approximately 2:30 PM confirmed the above supplies and products were expired.

6) An observation on April 18, 2012, at approximately 2:45 PM of the Three South-West Psychiatric Unit Medication Room revealed the following expired supplies and products: 28 3M Tegaderm sterile transparent dressings marked expired May 2010; and one Sure-Vue Serum/Urine hcG container marked expired August 2011.

An interview with EMP2 on April 18, 2012, at approximately 2:45 PM confirmed the above supplies and products were expired.

7) An observation on April 18, 2012, at approximately 2:50 PM of the Three South Psychiatric Unit Medication Room revealed the following expired supplies and products: BD Batec blood culture Procedural Trays marked expired June 2008; five Sure-Vue Serum/Urine hcG containers marked expired December 2008; one Sterile Suture removal tray marked expired August 2011; and one BD Vacutainer marked expired January 2007.

An interview with EMP2 on April 18, 2012, at approximately 2:50 PM confirmed the above supplies and products were expired.

8) An observation on April 18, 2012, at approximately 3:00 PM of the Three East Psychiatric Unit Medication Room revealed three VanishPoint Syringes marked expired March 2010.

An interview with EMP2 on April 18, 2012, at approximately 3:00 PM confirmed the above supplies and products were expired.

9) An observation on April 19, 2012, at approximately 11:00 AM of the Facility's main supply storage room revealed 10 hypodermic 22 gauge needle protection device packets marked expired March 2009.

An interview with EMP3 on April 19, 2012, at approximately 11:00 AM confirmed the above supplies and products were expired.

Based on record review and interview, the facility failed to provide a Master Treatment Plan (MTP) that included specific interventions for 7 of 12 active sample patients (A8, A10, B10, E7, G8, I10 and J7). Many of the interventions on the MTPs were generic tasks instead of being individualized for each patient. Six of 12 MTPs, (A8, A10, B10, D9, E7, and J7), had interventions that did not relate to an identified problem. These failures result in lack of guidance to staff regarding the specific interventions needed and the purpose for each, which can result in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review

1. The facility's policy and procedure, No. 550-001.4, dated 1/5/12, and titled "[Name of facility] for Comprehensive Treatment Policy and Procedure" states, "Interventions are multidisciplinary and describe the specific treatment and the frequency that it will be provided."

2. A new "Inpatient Psychiatry Interdisciplinary Treatment Plan" form was put into effect in March, 2012. The instructions on the form under the "Intervention" column stated, "Each intervention can apply to more than 1 primary problem. Check all that apply. All interventions are provided daily unless otherwise specified." When a treatment plan had more than one problem, there was no way to determine what intervention applied to what problem.

3. Specific patient findings

a. Generic Interventions:

1) Patient A8, Master Treatment plan (MTP) dated 4/3/12

Problem - "Not caring for ADLs [activities of daily living], frequent phone calls to friend, family, hospital, and MD [doctor], c/o [complained of] inability to cope, confused about prior medication administration."

Generic intervention on the MTP: "Order medication for safety, efficacy and adverse effect such as: [space blank]." (Physician, RN)

2) Patient A10, MTP dated 4/3/12

Problems - "Aggressive/assaultive behavior as evidenced by: violent behavior, attacked people." "Impulsive behavior without regard to consequence as evidenced by: acting out behavior without warning."

Generic interventions:
"Monitor medication for safety, efficacy and adverse effect such as VA (valproic acid) level, Haldol Decanoate 180mg 1M [intramuscular] q 2-4 wks [every two to four weeks]." (Physician, RN)

3) Patient B10, MTP dated 4/5/12

Problem - "Anxiety or agitation."

Generic Intervention: "Monitor medication for safety, efficacy and adverse effect. Adjust as indicated." "Provide education about medication and symptom management." (Physician, RN)

4) Patient E7, MTP dated 4/10/12

Problem - "Suicidal/self-injurious behaviors as evidenced by: suicidal thought/plan to O.D. [overdose], cut wrist."

Generic intervention: "Order and administer medication - Trazodone 50mg po hs [50 milligrams by mouth at hour of sleep]. Monitor medication for safety, efficacy and adverse effect such as drowsiness." (Physician, RN)

5) Patient G8, MTP dated 4/9/12

Problem- "Visual hallucinations. Things crawling & (and) moving. Mood disturbance (depression), sleep disturbance, hopelessness, anxiety or agitation, (decrease appetite, isolating, racing thoughts."

Generic intervention- Intervention "Monitor medication for safety, efficacy and adverse effect. Adjust as indicated." "Provide education about medication and symptom management." (Physician, RN)

6) Patient I10, MTP dated 4/9/12

Problem - "Inability to function or care for his/her self as evidence by: found wandering the street by police, stated he is living on the street after running away from home on 4/6/12."

Generic interventions: "Order and administer medication: Risperdal, Haldol." "Monitor medication for safety, efficacy and adverse effect such as EPS [extrapyramidal symptoms], sedation." (Physician, RN), "Group sessions up to 2 times per week targeting: relaxation, social awareness/skills." (RN)

7) Patient J7, MTP dated 4/6/12

Problems - "Suicidal/self-injurious behaviors as evidenced by: thoughts to cut wrist." "Aggressive assaultive behavior as evidenced by: thoughts to hurt others."

Generic interventions: "Order and administer medication: Haldol, Risperdal." "Monitor medication for safety, efficacy and adverse effect as: EPS, sedation." (Physician, RN)

b. Interventions not corresponding or relative to an identified problem:

1) Patient A8, MTP dated 4/3/12

Problems - "Auditory hallucinations, mood, disturbance [depression], sleep disturbance, hopelessness, anxiety agitation."

Non-corresponding intervention: "Monitor medication for safety, efficacy and adverse effect. Adjust as indicated." "Provide education about medication and symptom management." (Physician, RN)

2) Patient A10, MTP dated 4/3/12

Problem - "Inability to function or care for his/her self as evidenced by: meds, supervision for all ADLs."

Non-corresponding interventions: "Supportive psychotherapy 5 times per week targeting: [increased] reality testing." "Group sessions up to 14 times per week targeting: [increased] interventions." (Physician, RN, case manager)

Problems - "Mood disturbance [mania], sleep disturbance, anxiety or agitation."

Non-corresponding interventions: "Monitor medication for safety, efficacy and adverse effect. Adjust as indicated." "Provide education about medication and symptom management." (Physician, RN, case manager)

3) Patient B10, MTP dated 4/5/12

Problems - "Suicidal/self-injurious behaviors as evidenced by: threatening daily [with] mother when he does not get his way." "Aggressive/assaultive behavior as evidenced by: hits/fights peers + (plus) adults at school. Slams doors."

Non-corresponding interventions: "Monitor medication for safety, efficacy and adverse effect such as: sedation, wt [weight] gain." (Physician, RN)

4) Patient D9, MTP dated 4/9/12

Problem - "Suicidal/self-injurious behaviors as evidenced by: overdose on medication - Wellbutrin."

Non-corresponding intervention: "Supportive psychotherapy 5 times per week targeting: ventilation." (Physician)

5) Patient E7, MTP dated 4/10/12

Problem - "Impulsive behavior without regard to consequence as evidenced by: gambling heavily."

Non-corresponding intervention: "Monitor medication for safety, efficacy and adverse effect such as drowsiness." "Order and administer medication: Trazodone 50mg po hs [50 milligrams by mouth at hour of sleep]." (Physician, RN)

6) Patient J7, MTP dated 4/6/12

Problems - "Auditory hallucinations - hears voices to kill self/others."

Non-corresponding interventions: "Monitor medication for safety, efficacy and adverse effect. Adjust as indicated." "Provide education about medication and symptom management." "Provide reality based structured activities for troubling symptoms and to develop positive coping strategies such as: {space blank]." (Physician, RN)

B. Staff Interviews

1. In an interview on 4/11/12 at 8:58a.m., which included a discussion of the lack of specific interventions on many patients' Master Treatment Plans, MD1 stated, "We document specific problems and interventions in the progress notes."

2. In an interview on 4/11/12 around 9:05a.m., which included a discussion of the generic interventions, RN1 said, "There are some things we do for all patients."

3. In an interview on 4/11/12 at 9:56a.m., the lack of specificity with some interventions on the Master Treatment Plans was discussed with the Acting Nursing Director. The Acting Nursing Director did not dispute the findings.

Based on record review and interview, the facility failed to ensure that discharge summaries for 4 of 5 discharged patients whose records were reviewed (DC1, DC2, DC3, and DC5) contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge. This failure results in a lack of critical clinical information concerning the patient's level of psychiatric symptomatology and risk being readily available to aftercare providers.

Findings include:

A. Record Review

1. Patient DC1: In a discharge summary dated 3/27/12, the physician failed to document any recommendations regarding anticipated problems or suggested means of intervention.

2. Patient DC2: In a discharge summary dated 4/4/12, the physician failed to document any recommendations regarding anticipated problems or suggested means of intervention in a template section titled "Anticipated Problems and Suggested Means of Intervention."

3. Patient DC3: In a discharge summary dated 4/6/12, the physician failed to document any recommendations regarding suggested means of intervention in a template section titled "Means of Intervention."

4. Patient DC5: In a discharge summary dated 4/4/12, the physician failed to document any recommendations regarding anticipated problems or suggested means of intervention in a template section titled "Anticipated Problems and Suggested Means of Intervention."

B. Interview

In an interview on 4/11/12 at 9:30a.m., when shown the above patients' records, the Medical Director agreed that the discharge summary information was not present on the records.

21993

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

I. Ensure that clinical staff provided a Master Treatment Plan (MTP) that included specific interventions for 7 of 12 active sample patients (A8, A10, B10, E7, G8, I10, and J7). Many of the interventions on the MTPs were generic tasks instead of being individualized for each patient. Six of 12 MTPs, (A8, A10, B10, D9, E7 and J7), had interventions that did not relate to an identified problem. These failures result in lack of guidance to staff regarding the specific intervention needed and the purpose for each, which can result in inconsistent and/or ineffective treatment. (Refer to B122)

II. Ensure that for 4 of 5 discharged patients whose records were reviewed (DC1, DC2, DC3 and DC5), physicians dictated discharge summaries that contained psychiatric recommendations related to anticipated problems and suggested means of intervention after discharge. This failure results in a lack of critical clinical information concerning the patient's level of psychiatric symptomatology and risk being readily available to aftercare providers. (Refer to B135)

Based on record review and interviews, the Nursing Director failed to ensure that the Master Treatment Plans for 7 of 12 active sample patients (A8, A10, B10, E7, G8, I10 and J7) included specific nursing interventions. The listed nursing interventions were generic tasks instead of being individualized to meet each patient's needs. This failure results in lack of guidance to staff in determining the specific interventions needed and the purpose for each, which can result in inconsistent and/or ineffective treatment.

Findings include:

a. Patient A8, Master Treatment plan (MTP) dated 4/3/12

Problem - "Not caring for AOLs [activities of daily living], frequent phone calls to friend, family, hospital, and [doctors], c/o [complained of] inability to cope, confused about prior medication administration."

Generic nursing intervention on the MTP: "Order medication for safety efficacy and adverse effect such as: [space blank]."

b. Patient A10, MTP dated 4/3/12

Problems - "Aggressive/assaultive behavior as evidenced by: violent behavior, attacked people." "Impulsive behavior without regard to consequence as evidenced by: acting out behavior without warning."
Generic nursing intervention:
"Monitor medication for safety, efficacy and adverse effect such as VA (valproic acid level, Haldol Decanoate 150mg IM [intramuscular] q 2-4 wks [every two to four weeks]."

c. Patient B10, MTP dated 4/5/12

Problem - "Anxiety or agitation."

Generic nursing intervention: "Monitor medication for safety, efficacy and adverse effect. Adjust as indicated." "Provide education about medication and symptom management."

d. Patient E7, MTP dated 4/10/12

Problem - "Suicidal/self-injurious behaviors as evidenced by: suicidal thought/plan to O.D. [overdose], cut wrist."

Generic nursing intervention: "Order and administer medication - Trazodone 50mg po hs [50 milligrams by mouth at hour of sleep]. Monitor medication for safety, efficacy and adverse effect such as drowsiness."

e. Patient G8, MTP dated 4/9/12

Problem- "Visual hallucinations. Things crawling & (and) moving. Mood disturbance (depression), sleep disturbance, hopelessness, anxiety or agitation, (decrease appetite, isolating, racing thoughts."

Generic nursing intervention: "Monitor medication for safety, efficacy and adverse effect. Adjust as indicated." "Provide education about medication and symptom management."

f. Patient I10, MTP dated 4/9/12

Problem - "Inability to function or care for his/her self as evidence by: found wandering the street by police, stated he is living on the street after running away from home on 4/6/12."

Generic nursing interventions: "Order and administer medication: Risperdal, Haldol." "Monitor medication for safety, efficacy and adverse effect such as EPS [extrapyramidal symptoms], sedation." "Group sessions up to 2 times per week targeting: relaxation, social awareness/skills."

g. Patient J7, MTP dated 4/6/12

Problems - "Suicidal/self-injurious behaviors as evidenced by: thoughts to cut wrist." "Aggressive assaultive behavior as evidenced by: thoughts to hurt others."

Generic nursing interventions: "Order and administer medication: Haldol, Risperdal." "Monitor medication for safety, efficacy and adverse effect as: EPS, sedation."

B. Staff Interviews

1. In an interview on 4/11/12 around 9:05a.m., which included a discussion of the generic interventions, RN1 said, "There are some things we do for all patients."

2. In an interview on 4/11/12 at 9:56a.m., the lack of specificity with some interventions on the Master Treatment Plans was discussed with the Acting Nursing Director. The Acting Nursing Director did not dispute the findings.