Bringing transparency to federal inspections
Tag No.: A0115
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Patient Rights as evidenced by:
1) Failing to ensure that MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (Acute Adult Unit);
1 (#F10) of 4 ( #FR7, #FR8, #F10, #F12) current patients on Visual Contact Precautions on the Live Oak Unit (Adolescent Unit);
2 ( #F3 and #F15) of 2 ( #F3 and #F15) current patients on Visual Contact Precautions on the Esplanade II Unit (see findings in tag A0144) .
2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others. (see findings in tag A0144).
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30984
Tag No.: A0144
Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to ensure the MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
-3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (Acute Adult Unit);
-1 (#F10) of 4 ( #FR7, #FR8, #F10, #F12) current patients on Visual Contact Precautions on the Live Oak Unit (Adolescent Unit) out of a total of 6 active patients on the Live Oak Unit.
-2 (#F3 and #F15) out of 2 current patients on Visual Contact Precautions on the Esplanade II Unit out of a total of 12 active patients.
2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others.
Findings:
1) Failing to ensure the MHTs observed patients according to Physician's Orders and hospital policy:
Review of the hospital policy titled "Level of Observation and Precaution", policy number TX7-1001, revised 03/20/14, and presented as the current policy by SF1Director of Clinical Services, revealed that the types of observations were Routine Observation (every 15 minutes direct observation of the location and activity of the patient is documented), Close Staff Sight (CSS) (every 10 minutes direct observation of the location and activity of the patient is documented), Visual Contact (VC) (maintain visual contact of the patient at all times), and One-to-One (1:1) (one staff member assigned within 3 to 6 feet of visual contact of the patient at all times during waking hours; during sleeping hours the staff member assigned will monitor the client from the bedroom doorway). Further review revealed the types of precautions include Suicide Precautions, Elopement Precautions, Fall Precautions, Seizure Precautions, and Withdrawal Precautions. At admission all patients will be placed on Routine Observation, and the level of observation can be adjusted when a patient poses a risk of harm to self, others, or property at the time of admission or in response to the Initial Nursing Assessment results. An order must be written to change a level of observation/precaution outside the initial placement of Routine Observation upon admission. The order must be written by a physician. If an order is written to discontinue a level of observation/precaution, the patient will revert back to Routine Observation, unless otherwise indicated in the physician's order. Review of the entire policy revealed no documented evidence of the procedure to follow when a patient on Suicide Precautions is in the bathroom to shower or perform hygiene activities.
Esplanade I Unit
During a tour of Esplanade I Unit on 05/29/14 at 10:20 a.m., SF10MHT was observed in the male's patient bathroom with the door ajar. Running water could be heard from the doorway. Further observation revealed upon entering the bathroom, the lavatories were located on the right wall, the toilet stalls were straight down the hall to the left, and around the corner (u-shaped bathroom) were 2 shower stalls with vinyl curtains hanging on rods that hung to the floor (could not see into the shower when the curtain was closed).
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT asked the surveyor if she was supposed to leave Patient #F5 who was Routine Observation with Suicide Precautions in the shower while she went to make her every 10 minute rounds on Patient #FR9 who was on CSS with Suicide Precautions and Patient #FR11 who was on CSS with Withdrawal Precautions and her every 15 minute rounds on Patient #FR10 who was Routine Observation with Suicide Precautions and Patient #FR12 who was on Routine Precautions. SF10MHT indicated she just started going into the bathroom with Suicide Precautions today, but she had been going into the bathroom with patients who were on every 10 minutes observation and 1:1. She further indicated that she had never had anyone explain to her how to handle other patients assigned to her when she was observing a patient in the shower. SF10MHT confirmed that she could not see Patient #F5 while he was in the shower, because the shower was around the corner from where she was standing in the doorway.
Review of the staff assignment sheet for 05/29/14 for the Esplanade I Unit presented by SF8Charge RN (Registered Nurse) revealed SF10MHT was assigned to observe Patients #FR9 (listed as CSS observation with Suicide Precautions), #FR10 (listed as Routine Observation with Suicide Precautions), #F5 (listed as Routine Observation with Suicide Precautions), #FR12 (listed as Routine Observation), and #FR11 (listed as CSS observation with Withdrawal Precautions).
Patient #F5
Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.
Review of Patient #F5's "Initial Care Orders" signed by SF16Medical Director on 05/28/14 at 6:15 p.m. revealed he was ordered to be on VC with no documented evidence of the type of precautions that were to be followed. His preliminary psychiatric diagnosis was Mood Disorder with a history of Asthma. Review of Patient #F5's "Doctor's Order Sheet" revealed an order written on 05/29/14 at 1:20 a.m. by SF15RN to change his precautions from VS (should be VC) to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
Review of Patient #F5's "Suicide Risk Assessment" included in his "RN Assessment of Risk/Initial Care Needs" and completed by SF15RN revealed Patient #F5's suicide risk was scored as a "4" by SF15RN (the factors checked totaled 5 rather than 4) with a score of 1 next to gender, Depression,use of alcohol within 72 hours, diagnosed or perceived chronic medical condition, and support system lacking. A note above the assessment on the form stated "if starred factors or three or more factors circled, then consider visual contact or 1:1." There was no documented evidence that SF15RN had reviewed her assessment with a physician as evidenced by the section for the time reviewed and the name of the physician being blank.
Review of Patient #F5's "Patient Observation & (and) Locator Form-Side 1" revealed he was placed on Routine Observation with Suicide Precautions on 05/28/14 at 10:45 p.m. when he was admitted. Review of his observation record for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered and for which he was being observed. Patient #F5 was not being observed by VC from his time of admission through 05/30/14 at 10:05 a.m. as ordered by SF16Medical Director.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #F5's observation status from VC to Routine Observation.
Patient #FR9
Review of Patient #FR9's medical record revealed he was admitted on 05/28/14 at 8:00 a.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:00 p.m. Further review revealed Patient #FR9 was PEC'd on 05/27/14 at 11:31 p.m. due to being suicidal, homicidal, and a danger to self and others. He was CEC'd (Coroner's Emergency Certificate) on 05/29/14 at 10:57 a.m. due to being a danger to himself. Review of his physician admit orders revealed SF16Medical Director ordered Patient #FR9 to be on VC with no special precautions. Review of his "Doctor's Order Sheet" revealed an order received by telephone from SF16Medical Director on 05/28/14 at 1:20 p.m. to change him to CSS with Suicide Precautions.
Review of Patient #FR9's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR9's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR9.
Patient #FR10
Review of Patient #FR10's medical record revealed he was admitted on 05/28/14 at 12:00 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 6:20 p.m. He was PEC'd on 05/27/14 at 6:15 p.m. due to being suicidal and dangerous to self. He was CEC'd on 05/28/14 at 12:00 p.m. as being suicidal and dangerous to self.
Review of Patient #FR10's admission orders signed by SF16Medical Director revealed an order for VC with no documented evidence of special precautions. Review of his "Doctor's Order Sheet" revealed a telephone order was received from SF17NP (Nurse Practitioner) to change from VC to CSS with Suicide Precautions. Further review revealed an order was written by SF15RN on 05/28/14 at 9:00 p.m. to change Patient #FR10's level of observation from CSS to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered. Review of the form for 05/28/14 revealed no documented evidence of the level of observation or the type of precaution that was ordered.
Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR10's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR10.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #FR10's observation status from CSS to Routine Observation.
Patient #FR11
Review of Patient #FR11's medical record revealed she was admitted on 05/26/14 at 3:55 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:45 p.m. Further review revealed she was PEC'd on 05/25/14 at 2:55 p.m. due to being gravely disabled and CEC'd on 05/27/14 at 11:09 a.m. due to being gravely disabled. Review of her physician admit orders revealed Patient #FR11 was ordered to be on VC. There was a telephone order received from SF16Medical Director on 05/26/14 at 5:30 p.m. to change her observation status to CSS.
Review of Patient #FR11's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR11's 10:20 a.m. observation had not been made as evidenced by the space for the 10:20 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:20 a.m. space had been completed by SF10MHT showing that Patient #FR11 was outside talking with peers.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:20 a.m. observation of Patient #FR11.
Patient #FR12
Review of Patient #FR12's medical record revealed she was admitted on 04/22/14 at 8:53 p.m. with a diagnosis of Paranoid Schizophrenia and a history of Crohn's Disease. Further review revealed she was ordered to be on CSS. Review of the physician's orders revealed a telephone order was received from SF16Medical Director on 05/10/14 at 5:10 p.m. for Routine Observation.
Review of Patient #FR12's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR12's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that Patient #FR12 was outside walking or pacing.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR12.
Live Oak Unit:
Patient #F10
Review of the medical record for Patient #F10 revealed he was a 14 year old male admitted to the hospital on 2/11/14 for diagnoses which included Depression, ADHD ( Attention Deficit Hyperactivity Disorder) and obesity.
Review of the Document entitled "Patient Observation and Locator Form", dated 5/29/14, revealed Patient #F10 was ordered to be on Visual Contact precautions for EP (Elopement Precautions).
Review of the document entitled Unit Census, Room Assignment and Legal Status, dated 5/29/14, for Live Oak Unit revealed the following: Level of Observation and Precaution: Patient #F10: EP/VC (Elopement Precautions/Visual Contact).
In an interview on 5/29/14 at 9:55 a.m., with SF13ChargeRN (Charge Nurse-Live Oak Unit), she said the following patients were on Visual Contact level of observation: #FR7-Visual Contact -unpredictable behavior, #FR8- Visual Contact -unpredictable behavior, #F10- Visual Contact- elopement precautions, #F12-Visual Contact- unpredictable behavior.
On 5/29/14 at 10:00 a.m. an observation was made of S14MHT monitoring 3 Visual Contact patients ( Patient #FR8- unpredictable behavior, Patient #F10-elopement precautions, and Patient #F12- unpredictable behavior) in the commons area. Patient #F10 was observed going into his room unattended twice during this observation period. Patient #F10 was not within direct line of sight of S14MHT on the two occasions when he was allowed to be in his room unattended by staff. An interview was conducted with S14MHT at the time of the observation and she confirmed she had not maintained direct visual contact with Patient #F10 on the two occasions when he went to his room unattended.
In an interview on 5/29/14 at 2:08 p.m. with SF2RNHouseSupv she confirmed one person should not be responsible for 3 visual contact patients. She said, " You can't keep your eyes on all 3 patients at all times ". SF2RNHouseSupv said no more than 2 visual contact patients should have been assigned to one staff member. She explained if more than two patients had been assigned to one staff member that staff member should have called for additional help.
Esplanade II Unit
Patient #F3
Record review revealed Patient #F3 was admitted to the facility on 5/28/14 at 1443 with the diagnoses of Paranoid Schizophrenia. Review of his physician order dated 5/28/14 at 1200 revealed an order for V.C. (Visual Contact). Review of the RN Assessment of Risk/Initial Care Needs dated 5/28/14 and timed as completed at 1536 revealed he was scored a 2 on the Suicide Risk Assessment. One point was because he was a male and the second point was scored because he had impaired judgment, increased confusion, and unable to see a solution. Visual Contact Observation was checked off as the precaution.
Patient #F15
Record review revealed Patient #F15 was admitted to the facility on 5/28/14 at 1500 with diagnosis of Bipolar Disorder. Review of the Physician Orders dated 5/28/14 at 1200 revealed an order for a level of observations of V.C. Review of Patient F15's RN Assessment Risk/Initial Care Needs form dated 5/28/14 and timed as completed at 1702 revealed the patient had a score of 2 with 1 starred item on the suicide risk assessment. The instructions for the Suicide Risk Assessment form stated if starred or three or more factors circled, then consider visual contact or 1:1. The items circled were that he was a male, which was 1 point, and he had impaired judgment, increase confusion, and unable to see solution, which was 1 point. The starred item was he had two (2) previous suicide attempts, 1 attempt was 4 months ago when he cut his own throat. Also listed was he had a past history of assaultive/homicidal ideation, he also had paranoia and command hallucinations. His presenting problem was listed as he was at his parents' house yelling and screaming at them because they were the devil. His parents called the police and then the patient started yelling at the police.
An interview was conducted with SF4MHT at 5/29/14 at 10:30 a.m. She reported she was in charge of 2 patients (Patient #F3 and Patient # F15) who were on visual contact observation. When questioned what visual contact means, she reported it meant she must have visual contact with the patients at all times. When she was asked to point out her patients, she reported one patient (#F15) was outside with another MHT and she was able to located Patient #F15 outside and point him out to the surveyor. When she went to locate her other patient (#F3), she reported she thought he was outside with the other MHT, but she was unable to locate him at that time. SF4MHT located Patient #F3 a few minutes later sitting in a chair in the dayroom unattended by staff. SF4MHT reported the treatment team must have taken the patient into meet with them and placed him in the day room in a chair after assessing him. SF4MHT then proceeded to ask the surveyor how she was supposed to observe one patient that was inside the building and one patient that was outside building at the same time.
An interview was conducted with SF1DirClinical Services on 5/30/14 at 2:50 p.m. She reported she spoke to SF4MHT and she confirmed she had not handed over her observation level forms to another MHT to do visual contact observations on Patient# F3 and #F15. SF1DirClinical Service reported the appropriate procedure for when the MHTs switched which patients they were observing, was for the MHTs to also switch observation forms.
2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others:
Esplanade I Unit:
Observations on Esplanade I Unit on 05/29/14 at 10:10 a.m. with SF23Director of Admissions present revealed the patient room doors had round door knobs and door hinges set wide enough apart to allow potential for ligature. Further observation revealed the door to Room Fa was unlocked. This door opened into the day room on the female side of Esplanade I Unit and contained multiple sheets and other linen that could be used as ligatures. Further observation of the male side of Esplanade I Unit revealed the patient room doors had round door knobs and door hinges set wide enough apart to allow potential for ligature. The hall's bathroom door had round knobs, and the door hinges were set wide enough apart to allow potential for ligature. The bathroom stall door handles were not flush against the door and presented a ligature risk. Further observation revealed another bathroom down the overflow hall of the unit that had round door knobs and door hinges set wide enough apart to allow potential for ligature. Further observation revealed bathroom stall door handles were not flush against the door and presented a ligature risk. The plumbing to the toilets were not encased and protected from tampering. There was a water temperature valve set into the wall with the door opened that presented a risk for tampering.
In an interview on 05/29/14 at 10:10 a.m., SF23Director of Admissions confirmed the above findings that remained as risks to patient safety since the previous survey.
Live Oak Unit:
On 05/29/14 at 9:55 a.m. during a tour of the Live Oak Unit, accompanied by SF22MilieuSpecialist, the following observations were made:
Live Oak Unit:
Bathrooms for both sides of the unit:
a. Two bathroom stall doors had hinges set wide enough apart to allow potential for ligature;
b. Door handles not flush to the two bathroom stall doors to allow for potential ligature.
On 5/30/14 at 4:29 p.m. an interview was conducted with SF20DirRiskMgt regarding the findings in the Live Oak Unit bathrooms which posed potential risk for High Risk patients ( at risk for harm to self and/or others). SF20DirRiskMgt explained the staff had been educated on the identified physical plant challenges and the potential risk they posed to the at risk population. He confirmed the safety risk issues identified in the bathrooms on the Live Oak Unit (Two bathroom stall doors had hinges set wide enough apart to allow potential for ligature and door handles not flush to the two bathroom stall doors to allow for potential ligature) had not been corrected as of 5/30/14.
Esplanade II Unit
During the initial hospital tour on 05/29/14 at 10 a.m., the following observations were made: Esplanade II Unit had round doorknobs (not anti-ligature) on all doors throughout the unit;
Room "fb" on Esplanade 2 Unit:
a. A gooseneck faucet with flanged handles was noted on the sink;
b. Exposed toilet plumbing;
c. Door handles were not flush to the two bathroom stall doors allowing a potential ligature risk;
d. Unprotected Water Temperature control valve box with knobs to adjust water temps for showers was noted to be open. The hot water temperature gauge had a maximum temperature of 140 degrees. No temperature control knobs were present in the shower and the water temperature had to be controlled by the valves and
e. Door hinges separated widely enough for potential ligature anchor on the bathroom stall doors.
All observations were confirmed by SF5RN.
Decatur Unit:
A tour was conducted on 05/29/14 at 9:55 a.m. with SF2RNHouseSupv (House Supervisor) on the Decatur Unit which houses adult men and women. The following observations were made during the tour:
a. Round doorknobs (not anti-ligature) on most interior doors on the unit.
b. Extended door hinges at top of interior doors which protrude out from the door for about 10 inches (not anti-ligature).
c. Beds on unit are metal frames off of the floor (not anti-ligature).
d. Bathroom-stall doors with non-flush door handles (not anti-ligature). Hinges on the bathroom stall doors are not anti-ligature.
e. Exposed pipes on toilets in bathrooms (not anti-ligature).
f. Sink in bathroom with extended faucet and round handles for hot/cold water controls (not anti-ligature).
In an interview on 05/29/14 at 10:45 a.m., SF2RNHouseSupv (House Supervisor) was asked if all of the environmental issues identified during the tour were potential ligature risks for the patients housed on the unit, and she replied, "Yes." She further indicated if a patient really wants to hurt themselves, they will find a way because they are very cunning, and that was why the patients on the units were monitored at least every 15 minutes.
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31048
Tag No.: A0273
Based on record review and interview the hospital failed to ensure the Quality Assurance Performance Indicator (QAPI) program measured, analyzed, and tracked quality indicators and other aspects of performance that assessed processes of care, hospital service and operations by failing to identify:
1. Nurses were changing levels of observation without a physician order;
2. Staff was not providing level of supervision as ordered per physician's orders and as set forth in hospital policy.
Findings:
Review of the hospital policy titled "Level of Observation and Precaution", policy number TX7-1001, revised 03/20/14, and presented as the current policy by SF1Director of Clinical Services, revealed that the types of observations were Routine Observation (every 15 minutes direct observation of the location and activity of the patient is documented), Close Staff Sight (CSS) (every 10 minutes direct observation of the location and activity of the patient is documented), Visual Contact (VC) (maintain visual contact of the patient at all times), and One-to-one (1:1) (one staff member assigned within 3 to 6 feet of visual contact of the patient at all times during waking hours; during sleeping hours the staff member assigned will monitor the client from the bedroom doorway). Further review revealed the types of precautions include Suicide Precautions, Elopement Precautions, Fall Precautions, Seizure Precautions, and Withdrawal Precautions. At admission all patients will be placed on Routine Observation, and the level of observation can be adjusted when a patient poses a risk of harm to self, others, or property at the time of admission or in response to the Initial Nursing Assessment results. An order must be written to change a level of observation/precaution outside the initial placement of Routine Observation upon admission. The order must be written by a physician. If an order is written to discontinue a level of observation/precaution, the patient will revert back to Routine Observation, unless otherwise indicated in the physician's order. Review of the entire policy revealed no documented evidence of the procedure to follow when a patient on Suicide Precautions is in the bathroom to shower or perform hygiene activities.
1)Nurses changing levels of observation without a physician order:
Esplanade I Unit
During a tour of Esplanade I Unit on 05/29/14 at 10:20 a.m., SF10MHT was observed in the male's patient bathroom with the door ajar. Running water could be heard from the doorway. Further observation revealed upon entering the bathroom, the lavatories were located on the right wall, the toilet stalls were straight down the hall to the left, and around the corner (u-shaped bathroom) were 2 shower stalls with vinyl curtains hanging on rods that hung to the floor (could not see into the shower when the curtain was closed).
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT asked the surveyor if she was supposed to leave Patient #F5 who was Routine Observation with Suicide Precautions in the shower while she went to make her every 10 minute rounds on Patient #FR9 who was on CSS with Suicide Precautions and Patient #FR11 who was on CSS with Withdrawal Precautions and her every 15 minute rounds on Patient #FR10 who was Routine Observation with Suicide Precautions and Patient #FR12 who was on Routine Precautions. SF10MHT indicated she just started going into the bathroom with Suicide Precautions today, but she had been going into the bathroom with patients who were on every 10 minutes observation and 1:1. She further indicated that she had never had anyone explain to her how to handle other patients assigned to her when she was observing a patient in the shower. SF10MHT confirmed that she could not see Patient #F5 while he was in the shower, because the shower was around the corner from where she was standing in the doorway.
Review of the staff assignment sheet for 05/29/14 for the Esplanade I Unit presented by SF8Charge RN (Registered Nurse) revealed SF10MHT was assigned to observe Patients #FR9 (listed as CSS observation with Suicide Precautions), #FR10 (listed as Routine Observation with Suicide Precautions), #F5 (listed as Routine Observation with Suicide Precautions), #FR12 (listed as Routine Observation), and #FR11 (listed as CSS observation with Withdrawal Precautions).
Patient #F5
Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.
Review of Patient #F5's "Initial Care Orders" signed by SF16Medical Director on 05/28/14 at 6:15 p.m. revealed he was ordered to be on VC with no documented evidence of the type of precautions that were to be followed. His preliminary psychiatric diagnosis was Mood Disorder with a history of Asthma. Review of Patient #F5's "Doctor's Order Sheet" revealed an order written on 05/29/14 at 1:20 a.m. by SF15RN to change his precautions from VS (should be VC) to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
Review of Patient #F5's "Suicide Risk Assessment" included in his "RN Assessment of Risk/Initial Care Needs" and completed by SF15RN revealed Patient #F5's suicide risk was scored as a "4" by SF15RN (the factors checked totaled 5 rather than 4) with a score of 1 next to gender, Depression,use of alcohol within 72 hours, diagnosed or perceived chronic medical condition, and support system lacking. A note above the assessment on the form stated "if starred factors or three or more factors circled, then consider visual contact or 1:1." There was no documented evidence that SF15RN had reviewed her assessment with a physician as evidenced by the section for the time reviewed and the name of the physician being blank.
Review of Patient #F5's "Patient Observation & (and) Locator Form-Side 1" revealed he was placed on Routine Observation with Suicide Precautions on 05/28/14 at 10:45 p.m. when he was admitted. Review of his observation record for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered and for which he was being observed. Patient #F5 was not being observed by VC from his time of admission through 05/30/14 at 10:05 a.m. as ordered by SF16Medical Director.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #F5's observation status from VC to Routine Observation.
Patient #FR9
Review of Patient #FR9's medical record revealed he was admitted on 05/28/14 at 8:00 a.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:00 p.m. Further review revealed Patient #FR9 was PEC'd on 05/27/14 at 11:31 p.m. due to being suicidal, homicidal, and a danger to self and others. He was CEC'd (Coroner's Emergency Certificate) on 05/29/14 at 10:57 a.m. due to being a danger to himself. Review of his physician admit orders revealed SF16Medical Director ordered Patient #FR9 to be on VC with no special precautions. Review of his "Doctor's Order Sheet" revealed an order received by telephone from SF16Medical Director on 05/28/14 at 1:20 p.m. to change him to CSS with Suicide Precautions.
Review of Patient #FR9's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR9's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR9.
Patient #FR10
Review of Patient #FR10's medical record revealed he was admitted on 05/28/14 at 12:00 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 6:20 p.m. He was PEC'd on 05/27/14 at 6:15 p.m. due to being suicidal and dangerous to self. He was CEC'd on 05/28/14 at 12:00 p.m. as being suicidal and dangerous to self.
Review of Patient #FR10's admission orders signed by SF16Medical Director revealed an order for VC with no documented evidence of special precautions. Review of his "Doctor's Order Sheet" revealed a telephone order was received from SF17NP (Nurse Practitioner) to change from VC to CSS with Suicide Precautions. Further review revealed an order was written by SF15RN on 05/28/14 at 9:00 p.m. to change Patient #FR10's level of observation from CSS to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered. Review of the form for 05/28/14 revealed no documented evidence of the level of observation or the type of precaution that was ordered.
Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR10's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR10.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #FR10's observation status from CSS to Routine Observation.
Patient #FR11
Review of Patient #FR11's medical record revealed she was admitted on 05/26/14 at 3:55 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:45 p.m. Further review revealed she was PEC'd on 05/25/14 at 2:55 p.m. due to being gravely disabled and CEC'd on 05/27/14 at 11:09 a.m. due to being gravely disabled. Review of her physician admit orders revealed Patient #FR11 was ordered to be on VC. There was a telephone order received from SF16Medical Director on 05/26/14 at 5:30 p.m. to change her observation status to CSS.
Review of Patient #FR11's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR11's 10:20 a.m. observation had not been made as evidenced by the space for the 10:20 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:20 a.m. space had been completed by SF10MHT showing that Patient #FR11 was outside talking with peers.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:20 a.m. observation of Patient #FR11.
Patient #FR12
Review of Patient #FR12's medical record revealed she was admitted on 04/22/14 at 8:53 p.m. with a diagnosis of Paranoid Schizophrenia and a history of Crohn's Disease. Further review revealed she was ordered to be on CSS. Review of the physician's orders revealed a telephone order was received from SF16Medical Director on 05/10/14 at 5:10 p.m. for Routine Observation.
Review of Patient #FR12's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR12's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that Patient #FR12 was outside walking or pacing.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR12.
2) Staff not providing level of supervision as ordered per physician orders and as set forth in hospital policy.
Esplanade II Unit
Patient #F3
Record review revealed Patient #F3 was admitted to the facility on 5/28/14 at 1443 with the diagnoses of Paranoid Schizophrenia. Review of his physician order dated 5/28/14 at 1200 revealed an order for V.C. (Visual Contact). Review of the RN Assessment of Risk/Initial Care Needs dated 5/28/14 and timed as completed at 1536 revealed he was scored a 2 on the Suicide Risk Assessment. One point was because he was a male and the second point was scored because he had impaired judgment, increased confusion, and unable to see a solution. Visual Contact Observation was checked off as the precaution.
Patient #F15
Record review revealed Patient#F15 was admitted to the facility on 5/28/14 on 1500 with diagnosis of Bipolar Disorder. Review of the Physician Orders dated 5/28/14 at 1200 revealed an order for a level of observations of V.C. Review of Patient #F15's RN Assessment Risk/Initial Care Needs form dated 5/28/14 and timed as completed at 1702 revealed the patient had a score of 2 with 1 starred item on the suicide risk assessment. The instructions for the Suicide Risk Assessment form stated if starred or three or more factors circled, then consider visual contact or 1:1. The items circled were that he was a male, which was 1 point, and he had impaired judgment, increase confusion, and unable to see solution, which was 1 point. The starred item was he had two (2) previous suicide attempts, 1 attempt was 4 months ago when he cut his own throat. Also listed was he had a past history of assaultive/homicidal ideation, he also had paranoia and command hallucinations. His presenting problem was listed as he was at his parent's house yelling and screaming at them because they were the devil. His parents called the police and then the patient started yelling at the police.
An interview was conducted with SF4MHT at 5/29/14 at 10:30 a.m. She reported she was in charge of 2 patients (Patient #F3 and Patient # F15) who were on visual contact observation. When questioned what visual contact means, she reported it meant she must have visual contact with the patients at all times. When asked for her to point out her patients, she reported one patient (#F15) was outside with another MHT and she was able to located Patient #F15 outside and point him out to the surveyor. When she went to locate her other patient (#F3), she reported she thought he was outside with the other MHT, but she was unable to locate him at that time. SF4MHT located Patient #F3 a few minutes later sitting in a chair in the dayroom unattended by staff. SF4MHT reported the treatment team must have taken the patient into meet with them and placed him in the day room in a chair after assessing him. SF4MHT then proceeded to ask the surveyor how was she supposed to observe one patient that was inside the building and one patient that was outside building at the same time.
An interview was conducted with SF1DirClinical Services on 5/30/14 at 2:50 p.m. She reported she spoke to SF4MHT and she confirmed she had not handed over her observation level forms to another MHT to do visual contact observations on Patient #F3 and #F15. SF1DirClinical Service reported the appropriate procedure for when the MHTs switched which patients they were observing was for the MHTs to also switch observation forms.
Live Oak Unit:
Patient #F10
Review of the medical record for Patient #F10 revealed he was a 14 year old male admitted to the hospital on 2/11/14 for diagnosis which included Depression, ADHD ( Attention Deficit Hyperactivity Disorder) and obesity.
Review of the Document titled "Patient Observation and Locator Form", dated 5/29/14, revealed Patient #F10 was ordered to be on Visual Contact precautions for EP (elopement precautions).
Review of the document entitled Unit Census, Room Assignment and Legal Status ,dated 5/29/14 for Live Oak Unit revealed the following: Level of Observation and Precaution: Patient #F10: EP/VC (Elopement Precautions/Visual Contact).
In an interview on 5/29/14 at 9:55 a.m., with SF13ChargeRN (Charge Nurse-Live Oak Unit), she said the following patients were on Visual Contact level of observation: #FR7-Visual Contact -unpredictable behavior, #FR8- Visual Contact -unpredictable behavior, #F10- Visual Contact- elopement precautions, #F12-Visual Contact- unpredictable behavior.
On 5/29/14 at 10:00 a.m. an observation was made of S14MHT monitoring 3 Visual Contact patients ( Patient #FR8- unpredictable behavior, Patient #F10-elopement precautions, and Patient #F12- unpredictable behavior) in the commons area. Patient #F10 was observed going into his room unattended twice during this observation period. Patient #F10 was not within direct line of sight of S14MHT on the two occasions when he was allowed to be in his room unattended by staff. An interview was conducted with S14MHT at the time of the observation and she confirmed she had not maintained direct visual contact with Patient #F10 when he went to his room unattended.
In an interview on 5/29/14 at 2:08 p.m. with SF2RNHouseSupv she confirmed one person should not be responsible for 3 visual contact patients. She said, "You can't keep your eyes on all 3 patients at all times ". She said no more than 2 visual contact patients should have been assigned to one staff member. She explained if more than 2 patients had been assigned to one staff member that staff member should have called for additional help.
Review of the hospital's corrective action plan for the Complaint Follow Up Survey (exit date: 5/30/14) revealed the following, in part:
7. Leadership rounds are being conducted to assess and monitor compliance with policy.
Leadership rounds consist of providing direct observation of staff and patients on the unit by a member of the Leadership team;
8. Camera reviews are being conducted to assess and monitor compliance with policy.
Review of the Executive Management Team- Performance Improvement Minutes, dated 4/22/14, revealed no documentation of identification that staff had not been providing the level of supervision as ordered per physician orders. Further review revealed nurses changing levels of observation without a physician order was not identified as a problem requiring intervention through QAPI.
In an interview on 5/30/14 at 4:29 p.m. with SF20DirRiskMgt, he confirmed the administrative staff had not been aware that staff had not been providing the level of supervision as ordered per physician orders. He said the administrative staff had been performing Leadership rounds and camera reviews to assess staff adherance to provision of patient monitoring . SF20DirRiskMgt said in hindsight it was difficult to identify the patient, their assigned staff and level of precaution by camera review. SF20DirRiskMgt also confirmed nurses changing levels of observation without a physician order had not been identified as a problem requiring intervention through QAPI.
30984
Tag No.: A0385
Based on observations, record reviews, and interviews, the hospital failed to meet the requirement for the Condition of Participation of Nursing Services as evidenced by:
1) Failing to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
a) Failure to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy for 2 (#F5, #FR10) of 6 (#F5, #F6, #FR9, #FR10, #FR11, #FR12) current patients' records reviewed on Esplanade I Unit (Acute Adult Unit) for physician orders to change the observation status from a total of 16 current patients on Esplanade I Unit and
b) Failure to ensure the MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
-3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (Acute Adult Unit) (see findings in tag A0395);
-1 (#F10) of 4 (#FR7, #FR8, #F10, #F12) current patients on Visual Contact Precautions on the Live Oak Unit (Adolescent Unit);
-2 (#F3 and #F15) of 2 (#F3 and #F15) current patients on Visual Contact Precautions on the Esplande II Unit.
An Immediate Jeopardy situation was identified on 05/30/14 at 11:06 a.m. and reported to SF21CEO on 5/30/14 at 3:40 p.m.. The Immediate Jeopardy was a result of the hospital failing to
a) ensure patients' level of supervision was not decreased by a nurse without a physician's order as required by hospital policy and
b) by failing to ensure patients at high risk were being monitored at the observation level as ordered per physician and as set forth in hospital policy.
Findings:
a)
Patient #F5 was admitted with physician orders on 5/28/14 at 6:15 p.m. after being PEC'd (Physician Emergency Certificate) on 5/28/14 at 2:00 p.m. as suicidal ( "Standing in the middle of the road telling passing drivers he wanted to kill himself " ). Patient #F5 was ordered to be on Visual Contact (maintain visual contact of patient at all times). His observation level was decreased from Visual Contact to Routine Observation ( every 15 minute observation) with Suicide Precautions by the RN without a physician's order for decrease. As of 5/30/14 at 10:20 a.m. Patient #F5 remained on Routine Observation rather than Visual Contact.
Patient #FR10, who was CEC'd (Coroner's Emergency Certificate), on 5/28/14 at 12:00 p.m. as suicidal and ordered to be on Close Staff Sight (every 10 minute observation) on 5/28/14 at 7:40 p.m. was changed from Close Staff Sight to Routine Observation with Suicide precautions on 5/28/14 at 9:00 p.m. by the RN. As of 5/30/14 at 10:20 a.m. Patient #FR10 has remained on Routine Observation rather than Close Staff Sight with Suicide Precautions.
b)
Patient #F3 and #F15 were ordered to be on Visual Contact Observation level on 5/28/14 (#F3 and #F15 were new admissions to the unit). An interview was conducted with a MHT ( Mental Health Technician) on 5/29/14 at 10:30 a.m. who was assigned to perform Visual Contact observations on Patient #F3 and Patient #F15. She reported Patient #F3 and Patient #F15 were being observed outside by another MHT. When the MHT went to locate Patient #F3 and Patient #F15 outside, the MHT was unable to find Patient #F3. Patient #F3 was located several minutes later inside the dayroom unsupervised by staff.
On 5/29/14 at 10:00 a.m. an observation was made of S14MHT monitoring 3 Visual Contact patients ( Patient #FR8- unpredictable behavior, Patient #F10-elopement precautions, and Patient #F12- unpredictable behavior) in the commons area. Patient #F10 was observed going into his room unattended twice during this observation period. Patient #F10 was not within direct line of sight of S14MHT on the two occasions when he was allowed to be in his room unattended by staff. An interview was conducted with S14MHT at the time of the observation and she confirmed she had not maintained direct visual contact with Patient #F10 on the two occasions when he went to his room unattended.
As the result of the hospital's action plan, the Immediate Jeopardy situation was removed on 05/30/14 at 6:40 p.m. due to the hospital doing the following:
a) Patients having observation change without accompanying MD order:
1. Immediately, all levels of observations of precautions will be reassessed. In addition, all orders will be re-evaluated to ensure patients have observations with an accompanying MD order.
2. Immediately all leadership rounds will focus on reviewing staff adherence to Level of Observation and Precautions Policy.
3. The Verbal order policy has been reviewed and execution has been operationally defined to maximize opportunities for staff compliance with the policy.
4. Precautions and Levels of Observation Policy has been reviewed and modified to operationally define execution of supervision requirements of the policy.
5. Medical Staff will meet to review and approve any changes or revisions to the existing policy.
6. The Governing Board will meet to review and approve any changes or revisions to the existing policy.
7. Beginning Immediately, re-training with the nurses on requirements to utilize verbal orders when important for patient welfare and timely treatment. Verbal orders are to be accepted and transcribed only by qualified and authorized personnel, authenticated within specific timeframe's.
a. Training will occur at the beginning of the shift via updated policies, handouts, and presentations.
b. Each staff member will sign an attestation that they have received and understood the updated policy and training materials.
c. Staff will not be allowed to work until they have received and completed training.
8. Immediately, leadership team will audit physician orders to ensure observation levels are changed with an accompanying MD authentication of the order.
a. Audits will occur daily for 30 days on each unit to ensure compliance. The hospital has a sustained goal of 100% expected compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated. If 100% compliance is not met, daily audits will be extended in increments of 30 days until 100% compliance is met,
b. After 30 days of 100% compliance, audits will be ongoing on each unit to ensure compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated.
b) Staff not maintaining precautions according to MD order:
1. Immediately, leadership team will directly observe staff adherence to the Levels of Observation and Precautions per policy per patient.
a. Audits will occur daily for 30 days on each unit to ensure compliance. The hospital has a sustained goal of 100% expected compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated. If 100% compliance is not met, daily audits will be extended in increments of 30 days until 100% compliance is met,
b. After 30 days of 100% compliance, audits will be ongoing on each unit to ensure compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated.
2. Precautions and levels of Observation policy has been reviewed and modified to operationally define execution of supervision requirements of the policy.
3. Medical Staff will meet to review and approve any changes or revisions to the existing policy.
4. The Governing Board will meet to review and approve any changes or revisions to the existing policy.
5. Designated rooms on each unit have been identified as a "safety bedroom" where patients on visual contact will be placed to ensure compliance with the policy.
6. Patients on Visual Contact will be grouped together on their assigned unit when not in their "safety bedroom" to ensure compliance with the policy. This includes times in the dayroom or other common areas of their assigned unit. This is not to be construed as "punitive" but strictly for safety of the patient.
7. Patient Observation forms will be color coded to maximize opportunities for compliance with the observation level using visual prompts.
8. Beginning immediately intensive re-training with the nurses, physicians, therapists and direct care staff on requirements of the policy regarding supervision of patients on precautions and the expectation of staff will be conducted to ensure compliance of the Levels of Observation and precautions policy.
a. Training will occur at the beginning of the shift via updated policies, handouts, and presentations.
b. Each staff member will sign an attestation that they have received and understood the updated policy and training materials.
c. Staff will not be allowed to work until they have received and completed training.
9. A member of the leadership team will provide direct observation of staff and patients via " leadership rounds" on the unit. The leadership team consists of Administrators, Department Heads, Supervisors, Managers, and Milieu Safety Specialists.
a. Leadership rounds will be completed at a minimum of 1 X (time) per day at random shifts by a designated member of the hospital leadership team. The hospital has a goal of 100% expected compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated.
ai. Leadership rounds will be completed at a minimum of 1 X per day at random shifts by a designated member of the hospital leadership team. The hospital has a goal of 100% expected compliance for at least 90 days. If compliance is not achieved staff re-education or progressive disciplinary action will occur as indicated.
1-a. Leadership rounds will be completed at a minimum of 1 X per day at
random shifts by a designated member of the hospital leadership team unless it is
determined that increased frequency is needed.
b. Camera reviews will be conducted at a minimum of 1X per shift on each unit by a member of the leadership team. The hospital has a goal of 100% expected compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated.
c. Random Q (every) - 15 minute observation forms will be conducted by members of the leadership team with a random sample of X3- Q 15 minute forms, per unit, per shift. The hospital has a sustained goal of 100% expected compliance for at least 90 days. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated.
d. If it is noted in any of the above monitoring that established policy and procedure is not being adhered to the following actions will occur:
di. If it is observed that the policy is not being adhered to, the manager conducting the rounds or observations will address the non-compliance immediately through the disciplinary process and report the non- compliance immediately to the CEO and Department Manager.
dii. If it is observed that the policy is not being adhered to, the offending staff will be re-educated on the policy and procedures and undergo progressive disciplinary action as indicated.
div. There will be ongoing refresher training's through change of shift briefings, annual training and monthly newsletters as well as annual competencies, performance evaluations and supervision to ensure sustained compliance with the policy and procedures.
10. All patients currently on Visual Contact have been re-assessed for the continued need for VC (Visual Contact) in keeping with the requirements for re-assessment of patients per policy.
11. Copies of the policy will be placed in Admissions and at each Nursing Station to ensure nursing, clinical, direct care staff and physicians understand the policy and have a guide to refer to when making decisions.
12. Copies of the Staff guidelines: levels of Observation/Guidelines for Supervision will be placed in the Admissions office and each Nursing Station for all staff to easily access.
13. The Governing Board will review the revised policy and effectiveness through review of monthly leadership reports, camera reviews and 24 hour reports every 15 days until the Board is satisfied the hospital is in full compliance with the policy.
14. Leadership has developed a schedule for face to face, "in the milieu training" capturing 100% of staff and covering all three shifts daily, that is intended to provide intensive training for effective milieu management. The focus is to help staff internalize all skills necessary for managing levels of supervision and precautions.
a. Effective 5/31/14, three members of leadership team will assume the role of coach and will assume an intensive presence that provides individualized coaching with opportunities for role playing and competence observation.
b. Effective 6/2/14, all members of leadership team will assume the role of coach and will assume an intensive presence that provides individualized coaching with opportunities for role playing and competence observation.
c. The intimate nature of the coaching sessions will not only provide opportunity to teach, but to answer questions, problem solve, in real time, using realistic and appropriate interventions and strategies that staff will use as a matter of course.
15. All staff identified as deficient during the survey has been re-trained and placed on performance improvement plans.
a. Competencies will continuously be evaluated as part of the plan.
b. Staff will be re-assessed over a 90 day period and performance documented daily by the supervisor in charge for the day.
16. All MHT's will be re-educated on all job related competencies.
a. 1:1 training of MHT ' s will be conducted by the Milieu Director, Associate Administrator, Director of Risk Management and Performance Improvement and Director of Clinical Services.
17. All nurses will be re-educated on all job related competencies.
a. 1:1 training of Nurses will be conducted by Director of Nursing and Assistant Director of Nursing.
Non-compliance continues at the Condition Level.
26351
30984
Tag No.: A0395
Based on observations, record reviews, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
1) Failing to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy for 2 (#F5, #FR10) of 6 (#F5, #F6, #FR9, #FR10, #FR11, #FR12) current patients' records reviewed on Esplanade I Unit (acute adult unit) for physician orders to change the observation status from a total of 16 current patients on Esplanade I Unit and
2) Failing to ensure the MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
-3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (acute adult unit).
-2 (Patient #F3 and Patient #F15) out of 2 current patients on visual contact (V.C.) on Esplanade II Unit;
-1 (#F10) of 4 ( #FR7, #FR8, #F10, #F12) current patients on Visual Contact Precautions on out of a total of 6 active patients on the Live Oak Unit (Adolescent Unit).
Findings:
1) Failing to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy:
Review of the hospital policy titled "Level of Observation and Precaution", policy number TX7-1001, revised 03/20/14, and presented as the current policy by SF1Director of Clinical Services, revealed that the types of observations were Routine Observation (every 15 minutes direct observation of the location and activity of the patient is documented), Close Staff Sight (CSS) (every 10 minutes direct observation of the location and activity of the patient is documented), Visual Contact (VC) (maintain visual contact of the patient at all times), and One-to-one (1:1) (one staff member assigned within 3 to 6 feet of visual contact of the patient at all times during waking hours; during sleeping hours the staff member assigned will monitor the client from the bedroom doorway). Further review revealed the types of precautions include Suicide Precautions, Elopement Precautions, Fall Precautions, Seizure Precautions, and Withdrawal Precautions. At admission all patients will be placed on Routine Observation, and the level of observation can be adjusted when a patient poses a risk of harm to self, others, or property at the time of admission or in response to the Initial Nursing Assessment results. An order must be written to change a level of observation/precaution outside the initial placement of Routine Observation upon admission. The order must be written by a physician. If an order is written to discontinue a level of observation/precaution, the patient will revert back to Routine Observation, unless otherwise indicated in the physician's order.
Patient #F5
Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.
Review of Patient #F5's "Initial Care Orders" signed by SF16Medical Director on 05/28/14 at 6:15 p.m. revealed he was ordered to be on VC with no documented evidence of the type of precautions that were to be followed. His preliminary psychiatric diagnosis was Mood Disorder with a history of Asthma. Review of Patient #F5's "Doctor's Order Sheet" revealed an order written on 05/29/14 at 1:20 a.m. by SF15RN to change his precautions from VS (should be VC) to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
Review of Patient #F5's "Suicide Risk Assessment" included in his "RN Assessment of Risk/Initial Care Needs" and completed by SF15RN revealed Patient #F5's suicide risk was scored as a "4" by SF15RN (the factors checked totaled 5 rather than 4) with a score of 1 next to gender, Depression,use of alcohol within 72 hours, diagnosed or perceived chronic medical condition, and support system lacking. A note above the assessment on the form stated "if starred factors or three or more factors circled, then consider visual contact or 1:1." There was no documented evidence that SF15RN had reviewed her assessment with a physician as evidenced by the section for the time reviewed and the name of the physician being blank.
In an interview on 05/29/14 at 2:45 p.m., SF19DON indicated that she had done one-to-one education with the nurses about needing a physician's order to change a patient's observation level, but she had not gotten to SF15RN yet.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN indicated "I'm new at the company and just do what the other nurses told me to do... can use our discretion" when asked if she had a physician's order to decrease the level of observation for Patient #F5. She confirmed that she did not get a physician's order to change Patient #F5's observation from VC to Routine Observation. SF15RN indicated that they do not have enough staff for everyone to be on VC, but if it's necessary, "I'd keep them on VC." She indicated that after she assessed Patient #F5, he told her that he was upset because his girlfriend had cheated on him. She further indicated that he was anxious to get to sleep and was placed on the side of the unit where a MHT was seated near his room most of the night. When asked if she was aware that he had been found in traffic telling drivers passing by that he wanted to kill himself, SF15RN answered, "he said he was trying to get to his daughter's house and never wanted to commit suicide." SF15RN indicated that she read Patient #F5's PEC. When the surveyor read what was written as stated above (about being found in traffic), she answered, "I read the PEC but sometimes I can't read the writing... I can't actually remember reading what you read to me." When asked if it was common practice for the nurses to change the patient's level of observation without obtaining a physician's order, SF15RN answered, "I'm not clear on it, but I'm going on what I'm trained on and wouldn't do what I haven't been trained on." She indicated that in the middle of the night "I don't have access to SF16Medical Director."
In an interview on 05/30/14 at 10:05 a.m., SF1Director of Clinical Services indicated that Patient #F5 remained on Routine Observation with Suicide Precautions. She confirmed that after administration was notified on 05/29/14 that there was no documented evidence that the order written by SF15RN to change Patient #F5's level of observation had been given by a physician, there had been no assessment made and a new order other than VC written by a physician as required by hospital policy.
Patient #FR10
Review of Patient #FR10's medical record revealed he was admitted on 05/28/14 at 12:00 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 6:20 p.m. He was PEC'd on 05/27/14 at 6:15 p.m. due to being suicidal and dangerous to self. He was CEC'd on 05/28/14 at 12:00 p.m. as being suicidal and dangerous to self.
Review of Patient #FR10's admission orders signed by SF16Medical Director revealed an order for VC with no documented evidence of special precautions. Review of his "Doctor's Order Sheet" revealed a telephone order was received from SF17NP (Nurse Practitioner) to change from VC to CSS with Suicide Precautions. Further review revealed an order was written by SF15RN on 05/28/14 at 9:00 p.m. to change Patient #FR10's level of observation from CSS to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN indicated she did not receive a physician's order to change Patient #FR10 from CSS to Routine Observation as required by hospital policy.
In an interview on 05/30/14 at 10:15 a.m., SF20Director of Risk Management indicated that Patient #FR10 was currently being observed as Routine Observation. When shown the order that was written by SF15RN and confirmed in the earlier interview that she did not receive the order from a physician, he confirmed that Patient #FR10 should have continued to be observed as CSS.
In an interview on 05/30/14 at 2:15 p.m. with SF16Medical Director, SF1Directorof Clinical Services, SF20Director of Risk Management, SF21Chief Executive Officer (CEO), and SF19Director of Nursing (DON) present, SF19DON indicated that because the RN has to evaluate a patient's suicide risk, SF15RN may have understood that she could change the level of observation. When told that SF15RN confirmed that she did not get a physician's order to change Patient #F5's observation level, and it was common practice for the nurses to change the observation levels without obtaining a physician's order, SF19DON offered no explanation. SF16Medical Director indicated that he did not remember getting a phone call from SF15RN requesting an order to change Patient #F5's level of observation. He further indicated that all patients on Esplanade I Unit were re-evaluated today and confirmed that this was not done on 05/29/14 when it was brought to the attention of administration.
2) Failing to ensure the MHTs observed patients according to Physician's Orders and hospital policy:
See the hospital policy titled "Level of Observation and Precaution", policy number TX7-1001, revised 03/20/14, and presented as the current policy by SF1Director of Clinical Services as written above under part 1. Review of the entire policy revealed no documented evidence of the procedure to follow when a patient on Suicide Precautions is in the bathroom to shower or perform hygiene activities.
Esplanade I Unit
During a tour of Esplanade I Unit on 05/29/14 at 10:20 a.m., SF10MHT was observed in the male's patient bathroom with the door ajar. Running water could be heard from the doorway. Further observation revealed upon entering the bathroom, the lavatories were located on the right wall, the toilet stalls were straight down the hall to the left, and around the corner (u-shaped bathroom) were 2 shower stalls with vinyl curtains hanging on rods that hung to the floor (could not see into the shower when the curtain was closed).
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT asked the surveyor if she was supposed to leave Patient #F5 who was Routine Observation with Suicide Precautions in the shower while she went to make her every 10 minute rounds on Patient #FR9 who was on CSS with Suicide Precautions and Patient #FR11 who was on CSS with Withdrawal Precautions and her every 15 minute rounds on Patient #FR10 who was Routine Observation with Suicide Precautions and Patient #FR12 who was on Routine Precautions. SF10MHT indicated she just started going into the bathroom with Suicide Precautions today, but she had been going into the bathroom with patients who were on every 10 minutes observation and 1:1. She further indicated that she had never had anyone explain to her how to handle other patients assigned to her when she was observing a patient in the shower. SF10MHT confirmed that she could not see Patient #F5 while he was in the shower, because the shower was around the corner from where she was standing in the doorway.
Review of the staff assignment sheet for 05/29/14 for the Esplanade I Unit presented by SF8Charge RN (Registered Nurse) revealed SF10MHT was assigned to observe Patients #FR9 (listed as CSS observation with Suicide Precautions), #FR10 (listed as Routine Observation with Suicide Precautions), #F5 (listed as Routine Observation with Suicide Precautions), #FR12 (listed as Routine Observation), and #FR11 (listed as CSS observation with Withdrawal Precautions).
Patient #F5
Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.
Review of Patient #F5's "Initial Care Orders" signed by SF16Medical Director on 05/28/14 at 6:15 p.m. revealed he was ordered to be on VC with no documented evidence of the type of precautions that were to be followed. His preliminary psychiatric diagnosis was Mood Disorder with a history of Asthma. Review of Patient #F5's "Doctor's Order Sheet" revealed an order written on 05/29/14 at 1:20 a.m. by SF15RN to change his precautions from VS (should be VC) to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
Review of Patient #F5's "Suicide Risk Assessment" included in his "RN Assessment of Risk/Initial Care Needs" and completed by SF15RN revealed Patient #F5's suicide risk was scored as a "4" by SF15RN (the factors checked totaled 5 rather than 4) with a score of 1 next to gender, Depression,use of alcohol within 72 hours, diagnosed or perceived chronic medical condition, and support system lacking. A note above the assessment on the form stated "if starred factors or three or more factors circled, then consider visual contact or 1:1." There was no documented evidence that SF15RN had reviewed her assessment with a physician as evidenced by the section for the time reviewed and the name of the physician being blank.
Review of Patient #F5's "Patient Observation & (and) Locator Form-Side 1" revealed he was placed on Routine Observation with Suicide Precautions on 05/28/14 at 10:45 p.m. when he was admitted. Review of his observation record for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered and for which he was being observed. Patient #F5 was not being observed by VC from his time of admission through 05/30/14 at 10:05 a.m. as ordered by SF16Medical Director.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #F5's observation status from VC to Routine Observation.
Patient #FR9
Review of Patient #FR9's medical record revealed he was admitted on 05/28/14 at 8:00 a.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:00 p.m. Further review revealed Patient #FR9 was PEC'd on 05/27/14 at 11:31 p.m. due to being suicidal, homicidal, and a danger to self and others. He was CEC'd (Coroner's Emergency Certificate) on 05/29/14 at 10:57 a.m. due to being a danger to himself. Review of his physician admit orders revealed SF16Medical Director ordered Patient #FR9 to be on VC with no special precautions. Review of his "Doctor's Order Sheet" revealed an order received by telephone from SF16Medical Director on 05/28/14 at 1:20 p.m. to change him to CSS with Suicide Precautions.
Review of Patient #FR9's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR9's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR9.
Patient #FR10
Review of Patient #FR10's medical record revealed he was admitted on 05/28/14 at 12:00 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 6:20 p.m. He was PEC'd on 05/27/14 at 6:15 p.m. due to being suicidal and dangerous to self. He was CEC'd on 05/28/14 at 12:00 p.m. as being suicidal and dangerous to self.
Review of Patient #FR10's admission orders signed by SF16Medical Director revealed an order for VC with no documented evidence of special precautions. Review of his "Doctor's Order Sheet" revealed a telephone order was received from SF17NP (Nurse Practitioner) to change from VC to CSS with Suicide Precautions. Further review revealed an order was written by SF15RN on 05/28/14 at 9:00 p.m. to change Patient #FR10's level of observation from CSS to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.
Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" for 05/29/14 and 05/30/14 revealed he was on Suicide Precautions with no documented evidence of the level of observation that was ordered. Review of the form for 05/28/14 revealed no documented evidence of the level of observation or the type of precaution that was ordered.
Review of Patient #FR10's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR10's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that he was in the dayroom watching television.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR10.
In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN confirmed that she did not receive a physician's order to change Patient #FR10's observation status from CSS to Routine Observation.
Patient #FR11
Review of Patient #FR11's medical record revealed she was admitted on 05/26/14 at 3:55 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 3:45 p.m. Further review revealed she was PEC'd on 05/25/14 at 2:55 p.m. due to being gravely disabled and CEC'd on 05/27/14 at 11:09 a.m. due to being gravely disabled. Review of her physician admit orders revealed Patient #FR11 was ordered to be on VC. There was a telephone order received from SF16Medical Director on 05/26/14 at 5:30 p.m. to change her observation status to CSS.
Review of Patient #FR11's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR11's 10:20 a.m. observation had not been made as evidenced by the space for the 10:20 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:20 a.m. space had been completed by SF10MHT showing that Patient #FR11 was outside talking with peers.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:20 a.m. observation of Patient #FR11.
Patient #FR12
Review of Patient #FR12's medical record revealed she was admitted on 04/22/14 at 8:53 p.m. with a diagnosis of Paranoid Schizophrenia and a history of Crohn's Disease. Further review revealed she was ordered to be on CSS. Review of the physician's orders revealed a telephone order was received from SF16Medical Director on 05/10/14 at 5:10 p.m. for Routine Observation.
Review of Patient #FR12's "Patient Observation & Locator Form-Side 1" during the interview with SF10MHT on 05/29/14 at 10:20 a.m. revealed Patient #FR12's 10:15 a.m. observation had not been made as evidenced by the space for the 10:15 a.m. location, behavior, and staff initials being blank. Review of the same record on 05/30/14 revealed that the 10:15 a.m. space had been completed by SF10MHT showing that Patient #FR12 was outside walking or pacing.
In an interview during the observation of SF10MHT in the male bathroom doorway on 05/29/14 at 10:20 a.m., SF10MHT confirmed that she had not made the 10:15 a.m. observation of Patient #FR12.
In an interview on 05/29/14 at 2:35 p.m., SF19DON indicated that she had done individual training with MHTs on the observation policy and precaution policy. She further indicated that SF10MHT had told her that she was nervous when she spoke with the surveyor on 05/29/14 and really knew how the observation was to be done. When the surveyor informed SF19DON that SF10MHT had approached the surveyor during the tour and asked how she was to observe her other 4 patients and maintain observation of Patient #F5 during his shower, SF19DON had no comment to offer.
Esplanade II Unit
Patient #F3
Record review revealed Patient #F3 was admitted to the facility on 5/28/14 at 1443 with the diagnoses of Paranoid Schizophrenia. Review of his physician order dated 5/28/14 at 1200 revealed an order for V.C. (Visual Contact). Review of the RN Assessment of Risk/Initial Care Needs dated 5/28/14 and timed as completed at 1536 revealed he was scored a 2 on the Suicide Risk Assessment. One point was because he was a male and the second point was scored because he had impaired judgment, increased confusion, and unable to see a solution. Visual Contact Observation was checked off as the precaution.
Patient #F15
Record review revealed Patient#F15 was admitted to the facility on 5/28/14 on 1500 with diagnosis of Bipolar Disorder. Review of the Physician Orders dated 5/28/14 at 1200 revealed an order for a level of observations of V.C. Review of Patient #F15's RN Assessment Risk/Initial Care Needs form dated 5/28/14 and timed as completed at 1702 revealed the patient had a score of 2 with 1 starred item on the suicide risk assessment. The instructions for the Suicide Risk Assessment form stated if starred or three or more factors circled, then consider visual contact or 1:1. The items circled were that he was a male, which was 1 point, and he had impaired judgment, increase confusion, and unable to see solution, which was 1 point. The starred item was he had two (2) previous suicide attempts, 1 attempt was 4 months ago when he cut his own throat. Also listed was he had a past history of assaultive/homicidal ideation, he also had paranoia and command hallucinations. His presenting problem was listed as he was at his parent ' s house yelling and screaming at them because they were the devil. His parents called the police and then the patient started yelling at the police.
An interview was conducted with SF4MHT at 5/29/14 at 10:30 a.m. She reported she was in charge of 2 patients (Patient #F3 and Patient # F15) who were on visual contact observation. When questioned what visual contact means, she reported it meant she must have visual contact with the patients at all times. When asked her to point out her patients, she reported one patient (F15) was outside with another MHT and she was able to located Patient F15 outside and point him out to the surveyor. When she went to locate her other patient (F3), she reported she thought he was outside with the other MHT, but she was unable to locate him at that time. SF4MHT located Patient #F3 a few minutes later sitting in a chair in the dayroom unattended by staff. SF4MHT reported the treatment team must have taken the patient into meet with them and placed him in the day room in a chair after assessing him. SF4MHT then proceeded to ask the surveyor how she was supposed to observe one patient that is inside the building and one patient that is outside building at the same time.
An interview was conducted with SF1DirClinical Services on 5/30/14 at 2:50 p.m. She reported she spoke to SF4MHT and she confirmed she had not handed over her observation level forms to another MHT to do visual contact observations on Patient #F3 and #F15. SF1DirClinical Service reported the appropriate procedure for when the MHTs switched which patients they were observing was for the MHTs to also switch observation forms.
Live Oak Unit (Adolescent Unit).
Patient #F10
Review of the medical record for Patient #F10 revealed he was a 14 year old male admitted to the hospital on 2/11/14 for diagnosis which included Depression, ADHD ( Attention Deficit Hyperactivity Disorder) and obesity.
Review of the Document titled "Patient Observation and Locator Form", dated 5/29/14, revealed Patient #F10 was ordered to be on Visual Contact precautions for EP (elopement precautions).
Review of the document entitled Unit Census, Room Assignment and Legal Status ,dated 5/29/14 for Live Oak Unit revealed the following: Level of Observation and Precaution: Patient #F10: EP/VC (Elopement Precautions/Visual Contact).
In an interview on 5/29/14 at 9:55 a.m., with SF13ChargeRN (Charge Nurse-Live Oak Unit), she said the following patients were on Visual Contact level of observation: #FR7-Visual Contact -unpredictable behavior, #FR8- Visual Contact -unpredictable behavior, #F10- Visual Contact- elopement precautions, #F12-Visual Contact- unpredictable behavior.
On 5/29/14 at 10:00 a.m. an observation was made of S14MHT monitoring 3 Visual Contact patients ( Patient #FR8- unpredictable behavior, Patient #F10-elopement precautions, and Patient #F12- unpredictable behavior) in the commons area. Patient #F10 was observed going into his room unattended twice during this observation period. Patient #F10 was not within direct line of sight of S14MHT on the two occasions when he was allowed to be in his room unattended by staff. An interview was conducted with S14MHT at the time of the observation and she confirmed she had not maintained direct visual contact with Patient #F10 on the two occasions when he went to his room unattended.
In an interview on 5/29/14 at 2:08 p.m. with SF2RNHouseSupv she confirmed one person should not be responsible for 3 visual contact patients. She said, " You can ' t keep your eyes on all 3 patients at all times". She said no more than 2 visual contact patients should have been assigned to one staff member. SF2RNHouseSupv explained if more than patients were assigned to one staff member that staff member should have called for additional help.
26351
Tag No.: A0396
Based on record reviews and interviews, the hospital failed to ensure that each patient's nursing care plan was kept current and was individualized as evidenced by failing to have patients' medical diagnoses included in their nursing care plans for 7 (#F4, #F5, #F6, #F7, #F9, #F11, #F12) of 16 (#1-#16) current patients' records reviewed for nursing care plans from a total of 16 sampled patients.
Findings:
Review of the policy entitled: Treatment Planning, last revised 4/24/14, revealed the following, in part:
Policy:
It is the policy of Northlake Behavioral Health System that treatment planning shall be performed by an interdisciplinary treatment team led by the treating physician in accordance with established time frames, meeting process format.
Purpose:
To assure that the patient/family/guardian, and all members of the treatment team have the opportunity to provide input into treatment planning and to assure development of a comprehensive and complete plan of care that serves as a guide for providing individualized
treatment.
Definitions: Plan of Care:
The individualized treatment plan, developed for each active problem/goal area that includes objectives, and interventions specific to the stated problem, as well as goals at discharge that capture the aftercare plan.
Problem List Acute, Extended Stay:
The problem list must be relevant to diagnoses and address the reason for admission. Problem Titles are guides for the clinician to use to develop goal statements. Each statement must be written in behaviorally specific terms that are achievable and measurable.
Patient #F4
Review of Patient #F4's medical record revealed he was admitted on 05/26/14 with a diagnosis of Mood Disorder. Review of his "Multidisciplinary Master Treatment Plan" revealed his diagnoses were Bipolar Disorder with Psychotic Features, Rule Out Schizoaffective Disorder, Hypertension, Post Traumatic Stress Disorder, and Chronic Pain.
Review of Patient #F4's individualized treatment plan revealed no documented evidence that a care plan was developed and initiated for Hypertension and Chronic Pain.
Patient #F5
Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.
Review of Patient #F5's physician admit orders revealed he
is diagnosis was Mood Disorder and and a history of Asthma. Further review revealed there was a physician's order for Albuterol inhaler as needed for shortness of breath or asthma.
Review of Patient #F5's "Multidisciplinary Master Treatment Plan" revealed no documented evidence that a care plan for impaired gas exchange had been developed.
Patient #F6
Review of Patient #F6's medical record revealed he was admitted on 05/14/14 with a diagnosis of Mood Disorder. Review of his Psychiatric Evaluation performed on 05/15/14 revealed his diagnoses included Schizophrenia, Chronic Paranoid Type, Cannabis Abuse by history, and Hypertension.
Review of Patient #F6's nursing care plan revealed no documented evidence that a care plan had been developed and initiated for Substance Abuse or Hypertension.
Patient #F7
Review of Patient #F7's medical record revealed Patient #F7 was a 44-year-old male admitted to the hospital on 05/14/14 per PEC (Physician's Emergency Certificate) with the diagnoses of Bipolar Disorder, Substance Abuse, Suicidal Ideation's, and Gout.
Review of Patient #F7's Multidisciplinary Master Treatment Plan revealed Patient #F7's treatment plans included a treatment plan for Depressed Mood, Chemical Dependency, Homelessness, and Illness Education. Further review of the medical record revealed there were no treatment plans developed or implemented for the diagnoses of Suicidal Ideations and Gout.
Patient #F9
Review of Patient #F9's medical record revealed Patient #F9 was a 36-year-old male admitted to the hospital on 05/21/14 per PEC (Physician's Emergency Certificate) with the diagnoses of Schizoaffective Disorder and Hypertension.
Review of the RN (Registered Nurse) Assessment, under the Cardiovascular System section, revealed "Hypertension" was checked off by the RN as a diagnosis. Review of the Initial Care Assessment, Determination of Level of Care Needed form revealed under the section, "Provisional Diagnosis, Axis III" section, a diagnosis of Hypertension was documented.
Review of the RN Rapid Assessment form, dated 05/21/14 at 6:00 p.m., revealed Patient #F9's blood pressure upon arrival to the unit was 136/97.
Review of Patient #F9's medical record revealed a treatment plan for "Depressed Mood and Suicidal Ideation." Further review of Patient #F9's medical record revealed there was no treatment plan developed or implemented for the diagnosis of Hypertension in Patient #F9's medical record.
Patient # F11
Review of Patient #F11's medical record revealed an admission date of 03/8/14 with Diagnoses including the following: ADHD (Attention Deficit Hyperactivity Disorder), Impulse Control Disorder, Mood Disorder, and GERD (Gastroesophageal Reflux Disease).
Review of Patient #F11's current treatment plan revealed no documented evidence that a care plan had been developed and initiated for GERD (Gastroesophageal Reflux Disease).
Patient # F12
Review of Patient #F12's medical record revealed an admission date of 05/24/14 with Diagnoses including the following: Asperger's Disorder, ADHD (Attention Deficit Hyperactivity Disorder) and Encoporesis ( holding of stool resulting in impacted stool collecting in the colon and leakage of liquid stool).
Review of Patient #F12's current treatment plan revealed no documented evidence that a care plan had been developed and initiated for Encoporesis.
In an interview on 05/30/14 at 2:15 p.m., SF1Director of Clinical Services indicated the medical problems of patients was not covered in the patients' nursing care plans and multidisciplinary treatment plans. She further indicated that it will take a lot of training to have the treatment plans done correctly.
30364
30984
31048
Tag No.: B0100
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Patient Rights as evidenced by:
1) Failing to ensure that MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
-3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (Acute Adult Unit);
-1 (#F10) of 4 ( #FR7, #FR8, #F10, #F12) current patients on Visual Contact precautions on the Live Oak Unit (Adolescent Unit);
-2 ( #F3 and #F15) of 2 ( #F3 and #F15) current patients on Visual Contact precautions on the Esplanade II Unit (see findings in tag A0144) .
2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others. (see findings in tag A0144).
Based on observations, record reviews, and interviews, the hospital failed to meet the requirement for the Condition of Participation of Nursing Services as evidenced by:
1) Failing to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
a) Failure to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy for 2 (#F5, #FR10) of 6 (#F5, #F6, #FR9, #FR10, #FR11, #FR12) current patients' records reviewed on Esplanade I Unit (acute adult unit) for physician orders to change the observation status from a total of 16 current patients on Esplanade I Unit and
b) Failure to ensure the MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
-3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (Acute Adult Unit) (see findings in tag A0395);
-1 (#F10) of 4 (#FR7, #FR8, #F10, #F12) current patients on Visual Contact Precautions on the Live Oak Unit (Adolescent Unit);
-2 (#F3 and #F15) of 2 (#F3 and #F15) current patients on Visual Contact Precautions on the Esplande II Unit.
An Immediate Jeopardy situation was identified on 05/30/14 at 11:06 a.m. and reported to SF21CEO on 5/30/14 at 3:40 p.m.. The Immediate Jeopardy was a result of the hospital failing to ensure patients' level of supervision was not decreased by a nurse without a physician's order as required by hospital policy and by failing to ensure patients at high risk were being monitored at the observation level as ordered per physician and as set forth in hospital policy.
As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 5/30/14 at 6:40 p.m.
Non- compliance continues at the Condition level
Tag No.: B0118
Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current an individualized comprehensive treatment plan which addressed all medical as well as psychological diagnoses for 9 ( #F1,#F2, #F4, #F5, #F6, #F7, #F9,#F11, #F12) of 16 (#F1 - #F16) current patients' records reviewed for nursing care plans from a total of 16 sampled patients.
Findings:
Review of the policy entitled: Treatment Planning, last revised 4/24/14, revealed the following, in part:
Policy:
It is the policy of Northlake Behavioral Health System that treatment planning shall be performed by an interdisciplinary treatment team led by the treating physician in accordance with established time frames, meeting process format.
Purpose:
To assure that the patient/family/guardian, and all members of the treatment team have the opportunity to provide input into treatment planning and to assure development of a comprehensive and complete plan of care that serves as a guide for providing individualized
treatment.
Definitions: Plan of Care:
The individualized treatment plan, developed for each active problem/goal area that includes objectives, and interventions specific to the stated problem, as well as goals at discharge that capture the aftercare plan.
Problem List Acute, Extended Stay:
The problem list must be relevant to diagnoses and address the reason for admission. Problem Titles are guides for the clinician to use to develop goal statements. Each statement must be written in behaviorally specific terms that are achievable and measurable.
Patient #F1
Review of the medical record for Patient #F1 revealed he was a 22 year old male admitted to the hospital on 5/27/14 on a Physician Emergency Certificate (PEC) for having suicidal Ideations and wanting to kill his self by overdosing on pills.
Review of his Multidisciplinary Master Treatment Plan revealed Problem #1 as Suicidal Ideations and his long term goal was to alleviate the suicidal impulses/ideation and return to the highest level of daily functioning. The only Clinical Intervention was Group psychotherapy 1 time a day /3 days a week. Patient #F1's second problem was "to try to deal with my problems: related to therapeutic tx (treatment) No long term goal was listed and the short term goals were to attend group with therapist, process coping skills in individual session(s) and work with therapist in finding placement. His Clinical intervention was to attend one group three (3) times a week.
Patient #F2
Review of the medical record for Patient #F2 revealed he was a 29 year old male admitted on 5/26/14 with suicidal ideations of killing his self with a razor and a history of schizophrenia. Review of his Psychiatric Evaluation dated 5/27/14 revealed he had bizarre behavior and was extremely paranoid.
Review of his Multidisciplinary Master Treatment Plan revealed Problem #1 was Altered Thoughts "to go home" related to history of mental illness and medication noncompliance as evidence by paranoid delusions and sexual (female) preoccupation. His long term goal was Patient's active psychotic symptoms are eliminated or controlled so that supervised functioning is positive and medication is taken consistently. His clinical interventions were listed as group psychotherapy 1 per day, 3 times a week and an educational group 1 per day 7 days a week, for one hour.
An interview was conducted with SF1DirClinicalServices on 5/30/14 at 2:15 p.m. She reported the treatment plans were not individualized for Patient F#1 and F#2.
Patient #F4
Review of Patient #F4's medical record revealed he was admitted on 05/26/14 with a diagnosis of Mood Disorder. Review of his "Multidisciplinary Master Treatment Plan" revealed his diagnoses were Bipolar Disorder with Psychotic Features, Rule Out Schizoaffective Disorder, Hypertension, Post Traumatic Stress Disorder, and Chronic Pain.
Review of Patient #F4's individualized treatment plan revealed no documented evidence that a care plan was developed and initiated for Hypertension and Chronic Pain.
Patient #F5
Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.
Review of Patient #F5's physician admit orders revealed his diagnoses included Mood Disorder and and a history of Asthma. Further review revealed there was a physician's order for Albuterol inhaler as needed for shortness of breath or asthma.
Review of Patient #F5's "Multidisciplinary Master Treatment Plan" revealed no documented evidence that a care plan for impaired gas exchange had been developed.
Patient #F6
Review of Patient #F6's medical record revealed he was admitted on 05/14/14 with a diagnosis of Mood Disorder. Review of his Psychiatric Evaluation performed on 05/15/14 revealed his diagnoses included Schizophrenia, Chronic Paranoid Type, Cannabis Abuse by history, and Hypertension.
Review of Patient #F6's nursing care plan revealed no documented evidence that a care plan had been developed and initiated for Substance Abuse or Hypertension.
Patient #F7
Review of Patient #F7's medical record revealed Patient #F7 was a 44-year-old male admitted to the hospital on 05/14/14 per PEC (Physician's Emergency Certificate) with the diagnoses of Bipolar Disorder, Substance Abuse, Suicidal Ideations, and Gout.
Review of Patient #F7's Multidisciplinary Master Treatment Plan revealed Patient #F7's treatment plans included a treatment plan for Depressed Mood, Chemical Dependency, Homelessness, and Illness Education. Further review of the medical record revealed there were no treatment plans developed or implemented for the diagnoses of Suicidal Ideations and Gout.
Patient #F9
Review of Patient #F9's medical record revealed Patient #F9 was a 36-year-old male admitted to the hospital on 05/21/14 per PEC (Physician's Emergency Certificate) with the diagnoses of Schizoaffective Disorder and Hypertension.
Review of the RN Assessment, under the Cardiovascular System section, revealed "Hypertension" was checked off by the RN (Registered Nurse) as a diagnosis. Review of the Initial Care Assessment, Determination of Level of Care Needed form revealed under the section, "Provisional Diagnosis, Axis III" section, a diagnosis of Hypertension was documented.
Review of the RN Rapid Assessment form, dated 05/21/14 at 6:00 p.m., revealed Patient #F9's blood pressure upon arrival to the unit was 136/97.
Review of Patient #F9's medical record revealed a treatment plan for "Depressed Mood and Suicidal Ideation." Further review of Patient #F9's medical record revealed there was no treatment plan developed or implemented for the diagnosis of Hypertension in Patient #F9's medical record.
Patient # F11
Review of Patient #F11's medical record revealed an admission date of 03/8/14 with Diagnoses including the following: ADHD (Attention Deficit Hyperactivity Disorder), Impulse Control Disorder, Mood Disorder, and GERD (Gastroesophageal Reflux Disease).
Review of Patient #F11's current treatment plan revealed no documented evidence that a care plan had been developed and initiated for GERD (Gastroesophageal Reflux Disease).
Patient # F12
Review of Patient #F12's medical record revealed an admission date of 05/24/14 with Diagnoses including the following: Asperger's Disorder, ADHD (Attention Deficit Hyperactivity Disorder) and Encoporesis ( holding of stool resulting in impacted stool collecting in the colon and leakage of liquid stool).
Review of Patient #F12's current treatment plan revealed no documented evidence that a care plan had been developed and initiated for Encoporesis.
In an interview on 05/30/14 at 2:15 p.m., SF1DirClinicalServices indicated the medical problems of patients was not covered in the patients' nursing care plans and multidisciplinary treatment plans. She further indicated that it will take a lot of training to have the treatment plans done correctly.
In an interview on 05/30/14 at 2:55 p.m. with SF1DirClinicalServices, she agreed treatment plans should have been inclusive of all medical and psychological diagnoses. SF1DirClinicalServices verified the treatment plan was not all inclusive if all problems were not addressed and the plan failed to contain measurable terms to determine whether goals had been achieved and/or if revision was needed.
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Tag No.: B0121
Based on record reviews and interviews, the hospital failed to ensure all problems identified for treatment (both medical and psychological) were addressed and contained short-term and long-term goals which were revised and included specific dates for expected achievement with written observable, measurable patient behaviors/relief of symptoms to be achieved for 7 ( #F1, #F2, #F4, #F5, #F6,#F11,#F12) of 7 (#F1, #F2, #F4, #F5, #F6, #F11,#F12) current patients' records reviewed for treatment plan goals from a total of 16 sampled patients.
Findings:
Review of the policy entitled: Treatment Planning, last revised 4/24/14, revealed the following, in part:
Policy:
It is the policy of Northlake Behavioral Health System that treatment planning shall be performed by an interdisciplinary treatment team led by the treating physician in accordance with established time frames, meeting process format.
Purpose:
To assure that the patient/family/guardian, and all members of the treatment team have the opportunity to provide input into treatment planning and to assure development of a comprehensive and complete plan of care that serves as a guide for providing individualized
treatment.
Definitions: Plan of Care:
The individualized treatment plan, developed for each active problem/goal area that includes objectives, and interventions specific to the stated problem, as well as goals at discharge that capture the aftercare plan.
Problem List Acute, Extended Stay:
The problem list must be relevant to diagnoses and address the reason for admission. Problem Titles are guides for the clinician to use to develop goal statements. Each statement must be written in behaviorally specific terms that are achievable and measurable.
Patient #F1
Review of the medical record for Patient #F1 revealed he was a 22 year old male admitted to the hospital on 5/27/14 on a Physician Emergency Certificate (PEC) for having suicidal ideations and wanting to kill his self by overdosing on pills.
Review of his Multidisciplinary Master Treatment Plan revealed Problem #1 as Suicidal Ideations and his long term goal was to alleviate the suicidal impulses/ideation and return to the highest level of daily functioning. The Clinical Intervention was Group psychotherapy 1 time a day /3 days a week. Patient #F1's second problem was "to try to deal with my problems: related to therapeutic tx (treatment) No long term goal was listed and the short term goals were to attend group with therapist, process coping skills in individual session(s) and work with therapist in finding placement. His Clinical intervention was to attend one group, three (3) times a week.
Patient #F2
Review of the medical record for Patient #F2 revealed he was a 29 year old male admitted on 5/26/14 with suicidal ideations of killing his self with a razor and a history of schizophrenia. Review of his Psychiatric Evaluation dated 5/27/14 revealed he had bizarre behavior and was extremely paranoid.
Review of his Multidisciplinary Master Treatment Plan revealed Problem #1 was Altered Thoughts "to go home" related to history of mental illness and medication noncompliance as evidence by paranoid delusions and sexual (female) preoccupation. His long term goal was Patient's active psychotic symptoms are eliminated or controlled so that supervised functioning is positive and medication is taken consistently. His clinical interventions were listed as group psychotherapy 1 per day, 3 times a week and an educational group 1 per day 7 days a week, for one hour.
An interview was conducted with SF1DirClinicalServices on 5/30/14 at 2:15 p.m. She reported the treatment plan's long range goals were not measurable for Patient #F1 and #F2.
Patient #F4
Review of Patient #F4's medical record revealed he was admitted on 05/26/14 with a diagnosis of Mood Disorder. Review of his "Multidisciplinary Master Treatment Plan" revealed his diagnoses were Bipolar Disorder with Psychotic Features, Rule Out Schizoaffective Disorder, Hypertension, Post Traumatic Stress Disorder, and Chronic Pain.
Review of Patient #F4's individualized treatment plan revealed no documented evidence that a care plan was developed and initiated for Hypertension and Chronic Pain.
Review of Patient #F4's treatment plan for "Withdrawal from alcohol and/or drugs" revealed the long term goal was that Patient #F4 will safely withdraw from alcohol and drugs with minimal physical complications. There was no documented evidence that the goal was written in observable, measurable patient behaviors to be achieved to know when this goal would be met. Further review revealed short-term goals were that vital signs will be within normal limits with the prescribed detoxification medications with no documented evidence of what was considered within normal limits for Patient #F4, that adequate nutrition, hydration, and elimination would be maintained with no documented evidence of how this goal would be measured to determine when it was met, and that Patient #F4 would establish a balance of rest, sleep, and activity with no documented evidence of the observable, measurable patient behaviors to be achieved to know when this goal would be met. Review of his treatment plan for "Paranoid Ideation" revealed the long term goal was that he would re-establish and maintain reality-based orientation that is free from suspicious thoughts. There was no documented evidence that the goal was written in observable, measurable patient behaviors to be achieved to know when this goal would be met. Review of his treatment plan for "Altered Thoughts" revealed the long term goal was that Patient #F4's active psychotic symptoms would be eliminated or controlled so that supervised functioning was positive and medication is taken consistently. There was no documented evidence that the goal was written in observable, measurable patient behaviors to be achieved to know when this goal would be met.
Patient #F5
Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.
Review of Patient #F5's physician admit orders revealed his diagnosis was Mood Disorder and and a history of Asthma. Further review revealed there was a physician's order for Albuterol inhaler as needed for shortness of breath or asthma.
Review of Patient #F5's "Multidisciplinary Master Treatment Plan" revealed no documented evidence that a care plan for impaired gas exchange had been developed.
Review of Patient #F5's treatment plan for "Depressed Mood" revealed his long term goal was that he would verbalize and demonstrate improved affect and mood prior to discharge and would return to his previous level of effective functioning. There was no documented evidence that the goal was written in observable, measurable patient behaviors to be achieved to know when this goal would be met.
Patient #F6
Review of Patient #F6's medical record revealed he was admitted on 05/14/14 with a diagnosis of Mood Disorder. Review of his Psychiatric Evaluation performed on 05/15/14 revealed his diagnoses included Schizophrenia, Chronic Paranoid Type, Cannabis Abuse by history, and Hypertension.
Review of Patient #F6's nursing care plan revealed no documented evidence that a care plan had been developed and initiated for Substance Abuse or Hypertension.
Review of Patient #F6's treatment plan for "Altered Thoughts" revealed his long term goal was that Patient #F6's active psychotic symptoms would be eliminated or controlled so that supervised functioning was positive and medication is taken consistently. There was no documented evidence that the goal was written in observable, measurable patient behaviors to be achieved to know when this goal would be met.
Patient # F11
Review of Patient #F11's medical record revealed an admission date of 03/8/14 with Diagnoses including the following: ADHD (Attention Deficit Hyperactivity Disorder), Impulse Control Disorder, Mood Disorder, and GERD (Gastroesophageal Reflux Disease).
Review of Patient #F11's current treatment plan revealed no documented evidence that a care plan had been developed and initiated for GERD (Gastroesophageal Reflux Disease).
Patient # F12
Review of Patient #F12's medical record revealed an admission date of 05/24/14 with Diagnoses including the following: Asperger's Disorder, ADHD (Attention Deficit Hyperactivity Disorder) and Encoporesis ( holding of stool resulting in impacted stool collecting in the colon and leakage of liquid stool).
Review of Patient #F12's current treatment plan revealed no documented evidence that a care plan had been developed and initiated for Encoporesis.
In an interview on 05/30/14 at 2:15 p.m., SF1DirClinicalServices indicated the medical problems of patients was not covered in the patients' nursing care plans and multidisciplinary treatment plans. She further indicated that it will take a lot of training to have the treatment plans done correctly. She further indicated that the treatment plans should have been inclusive of all medical and psychological diagnoses. SF1DirClinicalServices verified the treatment plan failed to contain measurable terms to determine whether goals had been achieved and/or if revision was needed.
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Tag No.: B0158
Based on record reviews and interviews, the hospital failed to ensure each patient was assessed by a recreational therapist for 4 (#F4, #F7, #F8, #F9) of 4 (#F4, #F7, #F8, #F9) current patients' records reviewed for a therapeutic recreational therapy assessment from a total of 16 sampled patients.
Findings:
Review of the policy entitled: Assessments, last revised 4/24/14, revealed the following, in part:
Policy:
It is the Policy of Northlake Behavioral Health to conduct initial and ongoing multidisciplinary assessments appropriate to the treatment setting, in accordance to designated time intervals.
Purpose:
To provide comprehensive evaluation of individual patient needs in order to identify and prioritize the appropriate treatment, care, and services for the patient.
Procedure:
F. Comprehensive Psychosocial Assessments:
Psychosocial Assessments that integrate an assessment of patient leisure interests and needs is completed within 72 hours of admissions, unless a patient is unable to participate actively in the evaluation. Psychosocial assessments capture all bio/psycho/social information in a strengths based, patient-centered way that honors a patient's right to be directly involved in assessing and planning for his/her care. When available, collateral information is used to complete a psychosocial evaluation. The therapist assigned to the patient is responsible for completion of the assessment.
Patient #F4
Review of Patient #F4's medical record revealed he was admitted on 05/26/14 with a diagnosis of Mood Disorder. Review of his "Multidisciplinary Master Treatment Plan" revealed his diagnoses were Bipolar Disorder with Psychotic Features, Rule Out Schizoaffective Disorder, Hypertension, Post Traumatic Stress Disorder, and Chronic Pain.
Review of Patient #F4's medical record revealed no documented evidence that he had a therapeutic recreational therapy assessment performed by a therapist trained to conduct such an assessment. Review of his "Psychosocial Assessment" documented by a Licensed Medical Social Worker (LMSW) revealed the following questions were listed for an "activity/leisure assessment": what kind of things stresses you; what makes you happy; leisure interests now and in the past; barriers to leisure activities; what do you want to improve during your treatment stay. There was no documented evidence that a treatment plan and goals were developed for Patient #F4 for therapeutic recreational therapy.
Patient #F7
Review of Patient #F7's medical record revealed Patient #F7 was a 44-year-old male admitted to the hospital on 05/14/14 per PEC (Physician's Emergency Certificate) with the diagnoses of Bipolar Disorder, Substance Abuse, Suicidal Ideations, and Gout.
Further review of the medical record revealed there was no initial therapeutic recreational therapy assessment performed on Patient #F7 by a therapist trained to conduct such as assessment.
Patient #F8
Review of Patient #F8's medical record revealed Patient #F8 was a 35-year-old female admitted to the hospital on 05/28/14 with the diagnoses of Bipolar Disorder, Depression; Substance Abuse, and Suicidal Ideation.
Further review of the medical record revealed there was no initial therapeutic recreational therapy assessment performed on Patient #F8 by a therapist trained to conduct such an assessment.
Patient #F9
Review of Patient #F9's medical record revealed Patient #F9 was a 36-year-old male admitted to the hospital on 05/21/14 per PEC (Physician's Emergency Certificate) with the diagnoses of Schizoaffective Disorder and Hypertension.
Further review of the medical record revealed there was no initial therapeutic recreational therapy assessment performed on Patient #F9 by a therapist trained to conduct such an assessment.
In an interview on 05/30/14 at 2:15 p.m., SF1Director of Clinical Services indicated she had the Master's prepared staff member (LMSW) perform the therapeutic recreational assessment as part of the psychosocial assessment and would have the recreational therapist do group therapy. She further indicated that the number of recreational therapy staff was limited to provide assessments for the number of patients who flow through in a short amount of time. She confirmed that the hospital had a certified music therapist on staff, but that individual couldn't keep up with the number of assessments that would be required with the turn-around of patients being admitted.
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