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Tag No.: A0022
Based on a review of facility documents, a review of medical records (MR) and interview with staff (EMP), it was determined that Haven Behavioral Hospital of Eastern Pennsylvania failed to conform to all applicable State laws.
Findings include:
Haven Behavioral Hospital of Eastern Pennsylvania was not in compliance with the following State law related to Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 PS. §1303.310.
Section 307. Patient safety plans. (a) Development and compliance.--A medical facility shall develop, implement and comply with an internal patient safety plan that shall be established for the purpose of improving the health and safety of patients. The plan shall be developed in consultation with the licensees providing health care services in the medical facility. (b) Requirements.--A patient safety plan shall: (1) Designate a patient safety officer as set forth in section 309. (2) Establish a patient safety committee as set forth in section 310. (3) Establish a system for the health care workers of a medical facility to report serious events and incidents which shall be accessible 24 hours a day, seven days a week. (4) Prohibit any retaliatory action against a health care worker for reporting a serious event or incident in accordance with the act of December 12, 1986 (P.L.1559, No.169), known as the Whistleblower Law. (5) Provide for written notification to patients in accordance with section 308(b).
Section 302. Definitions. "Incident." An event, occurrence or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. The term does not include a serious event. "Infrastructure failure." An undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility or the discontinuation or significant disruption of a service which could seriously compromise patient safety. "Serious event." An event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient. The term does not include an incident.
This is not met as evidenced by:
Based on review of personnel files, facility documents, and interview with staff (EMP), it was determined the facility failed to educate all personnel about their Patient Safety Plan, and failed to report events to the Patient Safety Authority and to the Department.
Findings include:
1) A review of personnel files including mandatory in-service documentation was conducted on June 21, 2012. It was determined that the facility personnel did not receive training in the facility patient safety plan.
An interview with the EMP1 confirmed that facility personnel did not receive training in the facility patient safety plan, nor was there a procedure in place to insure timely reporting of reportable events if the Patient Safety Officer were not available.
2) A review of Pharmacy documentation revealed that a suspected drug diversion occurred July 28, 2011, with the disappearance of 30 Clonopin tablets, a Schedule IV drug.
An interview conducted on June 21, 2012 with EMP4 revealed the entire container of Clonopin was missing. The DEA was notified and stated no further action was needed because of the class of the drug.
An interview conducted on June 21, 2012 with EMP5 revealed that the Patient Safety Officer was unaware of the specific requirements of the Law regarding the reporting of missing Schedule IV drugs to the Department through the Patient Safety Reporting System.
Tag No.: A0144
Based on review of medical records (MR), and staff interviews (EMP), it was determined the facility failed to provide a safe setting for one of one patients (MR7).
Findings:
A review on June 22, 2012, of facility policy "Levels of Observation, effective 9/1/10" revealed "All patients will be closely observed in compliance with physician orders and prescribed protocols...1. The physician will order one of three levels of observation at time of admission patients and as the patient's condition warrants a change...8. One-to-One Observation (1:1) ... Staff will stay within close proximity to the patient on 1:1 observation..."
A review on June 21, 2012 of MR7 revealed a physician order for "1:1 observation." The review of the "restraint/seclusion progress note" dated "2/ 20/12, 23:10"[sic] revealed, " Pt [patient] was sitting on toilet per male tech on pt's 1:1 observation- stated she had to urinate. A female tech walked into room to check on them during 15 minute checks and asked male tech where pt was. Stated she was using the restroom. Female tech peered into bathroom and patient had her hospital gown tied around her neck very tight. Both techs yelled for help and removed gown from pt.... "
An interview conducted on June 21, 2012 with EMP2 confirmed the patient was on a level and was not watched according to policy.
Tag No.: A0166
Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that Haven Behavioral Hospital of Eastern Pennsylvania failed to ensure that the use of restraint was in accordance with a written modification to the patients Plan of Care for 6 of 7 restraint medical records reviewed (MR3, MR4, MR5, MR6, MR7 and MR8).
Findings:
A review on June 22, 2012, of facility policy "Restraints, effective date 11/ 2011" revealed "Policy: ... Physical Restraint ... Mechanical Restraint ... Procedure ... The treatment plan shall be reviewed and revised following the first episode of restraints to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more then one occasion.... Seclusion ... Procedure ... The treatment plan shall be reviewed and revised following the first episode of seclusion to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is secluded on more than one occasion...."
A review on June 21 and 22, 2012, of MR3, MR4, MR5, MR6, MR7 and MR8 revealed all contained orders and documentation of the use of various restraints and/or seclusion. The treatment plans for MR3, MR4, MR5, MR6, MR7 and MR8, did not address restraints or seclusion.
An interview conducted on June 22, 2012, with EMP2, confirmed that the restraints or seclusion episodes were not addressed in the treatment plans.
Tag No.: A0396
Based on review of facility documentation, review of medical records (MR), and staff interview (EMP), it was determined that the facility failed to keep a current treatment plan and failed to include medically diagnosed conditions with ongoing treatments for three of 27 medical records reviewed (MR1, MR4, and MR13).
Findings include:
A review on June 21, 2012, of Haven Behavioral Hospital of Eastern Pennsylvania Policy, "Treatment Plan - Interdisciplinary", Effective date: 09/01/2010, last reviewed March 2011, revealed, "Purpose ... Policy ... Procedure ... 2. Within 72 hours of admission, members of the treatment team shall further develop the Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status.... 9. Identified medical problems that are stable but the patient is receiving medication/treatment for the problems, and need to be continually assessed for exacerbation, may be combined under the problem title "Medical Problems". Goals and interventions will be addressed for each identified medical problem...."
Review on June 20, 2012, of MR1, and MR4, for current inpatients, revealed the patients had medical conditions that required medications and monitoring. Review of the Treatment Plans for MR1 and MR4 revealed the treatment plans did not contain information regarding the patients' medical conditions.
An interview conducted on June 20, 2012, at 10:00 AM with EMP2 confirmed that MR1 and MR4 contained documentation of ongoing medical problems that were not addressed in the treatment plan .
Review on June 21, 2012, of MR13, for an inpatient who was discharged in April 2012, revealed the patient had medical conditions that required medications and monitoring. Review of the Treatment Plan for MR13 revealed the treatment plan did not contain information regarding the patient's medical conditions.
An interview conducted on June 21, 2012, at 4:30 PM, with EMP1, confirmed that the patient did have several ongoing medical conditions that were not addressed in the treatment plan. EMP1 further stated that the facility's Interdisciplinary Treatment Plans did not contain medical conditions and treatments.
Tag No.: A0654
Based on review of facility documents, and staff interview, it was determined that the facility did not have a utilization review committee.
Findings:
A review conducted on June 21, 2012, of Haven Behavioral Hospital Policies and Procedures, "Utilization Management and Monitoring", last reviewed January 01, 2011, revealed the necessity of Utilization Review Committee meetings was not addressed in the facility policy.
An interview conducted on June 21, 2012, at 1:30 PM, with EMP3, revealed the facility did not have a Utilization Review Committee.
Tag No.: A0700
Based on a Life Safety Code Validation survey, the Condition for Physical Environment is not met based on the results of the Department of Safety Inspection survey completed on July 7, 2012. See the Life Safety Code survey 2567 for the deficiencies.
Tag No.: A0724
Based on review of facility documents, observation, and staff interview, it was determined that the facility failed to maintain supplies to ensure an acceptable level of safety and quality.
Findings include:
A review conducted on June 22, 2012, of facility policy "Medication Safety, Unusable Drugs and Devices, effective March 2011," revealed "...1. Definition of Unusable Drugs and Devices: Unusable drugs and devices include those that are unfit to be administered to patients. a. expired, b. recalled, c. defective, d. contaminated, e. broken of deteriorated(physically or chemically), f. Mislabeled (improper, illegible, missing, or worn), g. Otherwise unsuitable for administration or use. 2. Return of unusable drugs and devices to the pharmacy: Unusable drugs or devices should not be distributed or administered. Pharmacy, nursing, and other personnel who discover unusable drugs and devices should return them to the pharmacy for proper disposition...."
Observation on June 20, 2012, of the medication room on the Geriatric Unit revealed 19 cotton top applicators with an expiration date of 8-2011, and a bottle of baby powder that was labeled for a patient that was admitted on November 11, 2111.
An interview conducted on June 20, 2012 at 11:00 AM with EMP1 confirmed that the cotton top applicators were expired and that the patient was discharged. Further interview revealed that the baby powder should have been discarded
Observation on June 20, 2012, of the lab draw area on the Geriatric Unit revealed three boxes of red top specimen tubes used for blood specimens with an expiration date of 02-2012.
An interview conducted on June 20, 2012 at 11:20 AM with EMP1 confirmed that specimen tubes were expired.
Observation on June 20, 2012, of the supply room on the Adult Unit revealed one bottle of isopropyl alcohol with an expiration date of October 2008, and two mono-flo drainage bags with an expiration dates of October 2011
An interview conducted on June 20, 2012 at 11:35 AM with EMP1 confirmed that the supplies were expired.
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A review of the product insert for the glucometer control solution revealed " ...About the control solutions ... Write the date you opened the bottle on the bottle label. The control solution is good for three months from that date ..."
Observation on June 20, 2012, of the medication room on the Adult Unit revealed the two glucometer control solution was labeled "exp 6/13/12" and "exp 6/15/12".
An interview conducted on June 20, 2012 at 11:35 AM with EMP1 confirmed that the glucometer control solution bottels were labeled exp 6/13/12 and exp 6/15/12. Further interview with EMP1 revealed that the staff may have mislabeled the bottles and that the staff was not sure of the date the bottles were opened
Tag No.: B0122
Based on record review and interview, the facility failed to establish individualized treatment modalities for 7 of 8 active sample patients (A1, A2, A3, A4, A5, A6, and A8). This resulted in interventions that were generalized and thus did not allow for a focus of treatment. In addition, no interventions were listed for the physician for 5 of 8 active sample patients (A1,A2,A4,A5,A6), and no Social work interventions were listed for 1 of 8 active sample patients (A2).
Findings include:
A. Record Review
1. Patient A1, master treatment plan dated 6/18/12. For problem #1, "dementia with depression", as well as medical problems of constipation and benign prostatic hypertrophy, interventions were "group process/reminiscence and coping" and "coping and grief skills to focus on what [pt] has instead of what [pt] had".
No intervention was listed for physician.
2. Patient A2, master treatment plan dated 5/29/12. For problem #1, "major depression with psychosis," interventions included "take medication daily as prescribed" and "daily personal hygiene and showers."
No interventions were listed for physician or social work.
3. Patient A3, master treatment plan dated 6/18/12. For problem #1, "hallucinations," interventions included "assess for presence of hallucinations every shift", "psycho education group twice per week," and "assess patient's level of understanding regarding the need for medication every shift."
4. Patient A4, master treatment plan dated 6/13/12. For problem #1, "psychotic symptoms with aggression," interventions included "provide opportunities for 1:1 conversations every shift while awake," and "reorient patient whenever delusional symptoms interfere with reality."
No intervention was listed for physician.
5. Patient A5, master treatment plan dated 6/9/12. For problems of suicidal thoughts, auditory hallucinations, multiple psychiatric and medical medications, including Lithium and Coumadin, interventions included "provide opportunities for 1:1 conversations daily," "initiate a suicide safety plan."
No intervention was listed for physician.
6. Patient A6, master treatment plan dated 4/30/12. For problems of paranoid delusions, multiple psychiatric and medical medications, diabetes, interventions included "process group and medication groups," "reorient patient when delusions interfere with reality," "assist patient in developing a plan and strategies to manage anxiety and paranoia."
No intervention was listed for physician.
7. Patient A8, master treatment plan dated 6/15/12. For problems of delusions, homicidal behavior, sexual behavior requiring 1:1 observation, interventions included "process group twice per week to identify feelings," "psycho-education group," "assess patient for homicidal ideation," "provide opportunities for 1:1 conversation to process feelings."
B. Staff Interviews
1. In an interview with the Medical Director on June 21, 2012, the Director agreed that the treatment plans did not include specific interventions.
2. In an interview with the Interim Director of Nursing on June 21, 2012, she agreed that there was a lack of specific interdisciplinary interventions for identified problems.
Tag No.: B0123
Based on record review and interview, the facility failed to identify specific staff responsible for interventions listed on the treatment plans of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This omission resulted in failure to document those staff responsible for assuring treatment modalities were consistently provided.
Findings include:
A. Record Review
For all 8 of 8 active sample patients' comprehensive treatment plans (A1, A2, A3, A4, A5, A6, A7, A8), the "Discipline and responsible staff" column of the treatment plans listed only generic term: terms for responsible staff included "MD", "NSG", "SW", and "MHT".
1. Patient A1, master treatment plan dated 6/18/12 used generic terms for responsible staff that included "RN", "AT", "SW", and "BHT". No intervention was listed for physician.
2. Patient A2, master treatment plan dated 5/29/12 used generic terms for responsible staff that included "RN" and "BHT". No interventions were listed for physician or social work.
3. Patient A3, master treatment plan dated 6/18/12 used generic terms for responsible staff that included "MD", "NSG", "SW", and "MHT".
4. Patient A4, master treatment plan dated 6/13/12 used generic terms for responsible staff that included "SW", "AT", "NSG", and "BHT". No intervention was listed for physician.
5. Patient A5, master treatment plan dated 6/12/12 used generic terms for responsible staff that included "SW", "AT", "NSG", and "BHT". No intervention was listed for physician.
6. Patient A6, master treatment plan dated 5/5/12 used generic terms for responsible staff that included "SW", "AT", "NSG" and "BHT". No intervention was listed for physician.
7. Patient A7, master treatment plan dated 6/18/12 used generic terms for responsible staff that included "AT", "SW", "NSG", "BHT" and "MD".
8. Patient A8, master treatment plan dated 6/15/12 used generic terms for responsible staff that included "AT", "MHT", "SW", "NSG" and "MD".
B. Staff Interviews
1. In an interview with the Medical Director on June 21, 2012, the Director agreed that the treatment plans did not include specific staff that was responsible for interventions.
2. In an interview with the Interim Director of Nursing on 6/21/12, she agreed that treatment plans did not include specific staff responsible for interventions.
Tag No.: B0144
Based on record review and interview, the Medical Director failed to adequately assure quality and appropriateness of services. Specifically, the Medical Director failed to ensure that:
A. Staff established individualized treatment modalities for 7 of 8 active sample patients (A1, A2, A3, A4, A5, A6, and A8). This resulted in interventions that were generalized and thus did not allow for a focus of treatment (Refer to B122).
B. Staff identified assigned treatment team members responsible for treatment interventions of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Instead, discipline titles were used to identify staff members responsible for ensuring compliance with particular aspects of a patient's multidisciplinary comprehensive treatment plan (Refer to B123).
Tag No.: B0148
Based on record review and interview, the Interim Director of Nursing failed to adequately assure that the treatment plans clearly delineated the nursing staffs' role in patient care. This can result in lack of accountability and fragmented nursing care for patients. Specifically, the Interim Director of Nursing failed to ensure that:
A. Staff established individualized treatment modalities for 7 of 8 active sample patients (A1, A2, A3, A4, A5, A6, and A8). (See B122)
B. Staff identified assigned treatment team members responsible for treatment interventions for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). (See B123)