HospitalInspections.org

Based on medical record reviews, interviews, hospital policies and observations the hospital failed to assure that the contracted services for the PPS Psych unit was in compliance with Federal requirements for hospital services. This had the potential to affect all patients served.

Findings include:

Refer to A 0130, A 0144 and A 0450 for findings.

Based on record reviews, observations, hospital policies and interviews the hospital failed to assure:

1. A safe environment was maintained for a suicidal patient and a wandering patient with dementia.
2. Photographs of patients wounds were not taken in a common area.
3. Appropriate training was provided to staff to ensure safety in handling patient behaviors.
4. Care plans were revised and included the patient or family in the planning process.
5. Care plans were updated to add or change interventions when changes occurred in the status of a patient.
6. Care plan goals were based upon the patient's assessment, were realistic, relevant, measurable and specific to the individual patient.
7. Care plans included discharging planning.

This had the potential to affect all patients served by the hospital.

Findings include:



Refer to A 0130 and A 0 144 for findings.

Based on a review of medical records, hospital policy and procedures and interview with administrative staff it was determined the hospital failed to:

1. Revise and have the patients or family be included in the development of the treatment plans.
2. Update the treatment plans to add or change interventions when a change occurs in the patient's status.
3. Assure the goals are based upon the patient's assessment and are realistic, relevant, measurable and specific to the individual patient.
4. Include discharge planning.

This had the potential to affect all patients served by the hospital and affected Medical Record numbers 1, 2, 3, 4, 6, 7, 10 and 12.

Findings include:

Policy: Multidisciplinary Treatment Planning
Revised: April 26, 2010

Policy: It is the policy of the Senior Care Unit that each patient will have a multi-disciplinary treatment plan (MDTP) based on assessments conducted by all disciplines. This plan will be used to direct the provision of care to patients and the treatment to each patient will be consistent among disciplines.

Procedure:
2.0- Within 24 hours of admission the history and physical will be completed, and within 60 hours the psychiatric evaluation will be completed. At this time an initial treatment plan will be documented in the patient's medical record by the attending physician.
6.0- Guidelines for treatment plans:
6.1- The treatment plan will identify problems and strengths/resources.
6.2- The treatment plan will identify goals of treatment.
6.2.1- Goals are based upon the assessments and are realistic, relevant, measurable, specific to the individual patient and consistent with the therapy prescribed by the medical practitioner.
6.2.2- Goals identify what the patient will accomplish in treatment.
6.2.3- Each treatment goal will be dated when it is identified.
7.0- Within 7 days of admission all disciplines, under the coordination of the attending physician will, at the Multidisciplinary Treatment Planning meeting, develop the Master Treatment Plan. This includes identification of patient strengths and assets, a comprehensive problem list, discharge planning and program and treatment interventions.
7.4- Interventions will be measurable and specific to the types of patients involved.
8.0- The treatment plan will be formally reviewed in the Multidisciplinary Treatment Planning meeting at 7-day intervals or more often if indicated.
9.1- When a change occurs in the patient's status, the treatment plan will be updated to provide needed interventions.

Medical Record Findings:

1. Medical Record (MR) # 2 was admitted to the Senior Care unit 8/31/10 with a diagnosis of Psychosis not otherwise specified (NOS).

The Interdisciplinary Treatment Plan in the medical record was dated 8/31/10. The plan was signed by the Psychiatrist, Social Worker, Activity Director, the Program Director, the RN (Registered Nurse) Manager, the RN who completed the admission assessment and a Licensed Practical Nurse (LPN).

The diagnosis on the form included:
Axis I: Psychosis NOS; Alcohol Dependence
Axis II: Mixed Personality Disorder
Axis III: Diabetes, Hypertension (HTN), Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Hepatitis C and Dysphagia
Axis IV: Severe- problems related to declining health
Axis V: 20.

The active problem list- psychiatric:
1. Psychosis NOS
2. Mixed Personality Disorder

The active problem list- medical:
3. Diabetes
4. HTN
5. COPD
6. GERD (gastro-esophageal reflux disease)
7. Atrial Fibrillation
8. Hypothyroidism
9. Potential for falls
10. Potential for impaired skin integrity.

There were no dates by the problem list diagnoses documented.

The Preliminary Discharge Plan was left blank, no discharge information was completed and no estimated length of stay was documented.
The area of Patient/Family involvement had documentation by the social worker dated 9/1/10, "Sister agreed by phone."

The social worker did not complete a psychosocial assessment until 9/3/10, 2 days after he documented the sister agreed by phone. The social worker signed the Interdisciplinary Treatment Plan as a participant on 8/31/10, prior to his assessment of the patient.

A second Interdisciplinary Treatment Plan in the medical record had several different dates on the form and it had page 1 of 2 on the form with a second page attached and labeled page 2 of 2.

The diagnosis on this form included:
Axis I: Psychosis NOS only with a date of 8/31/10, no other Axis diagnosis was present on the form.

The active problem list- psychiatric:
1. Psychosis NOS

The active problem list- medical:
2. Subdural Hematoma
3. IDDM ( insulin dependent diabetes mellitus)
4. HTN
5. COPD
6. Atrial Fibrillation
7. CHF (congestive heart failure)
8. Dysphagia
9. Potential for falls
10. Potential for impaired skin integrity.

The Preliminary Discharge Plan marked placement in alternative living arrangement, type: Nursing home. Estimated length of stay 10-14 days.

The plan was signed by the Psychiatrist, Social Worker, Activity Director, the Program Director, the RN (Registered Nurse) Manager, the RN who completed the admission assessment and the LPN case manager. The LPN case manager dated his signature as 9/2/10 as did the Program Director. The social worker dated his signature 9/6/10.

The area of Patient/Family involvement had documentation the patient was unable to sign and the sister agreed. This document was dated 8/31/10.

Page 2 of 2 was not signed by the Program Director or RN (Registered Nurse). The LPN case manager dated the second page 9/6/10.

The area of Patient/Family involvement had documentation by the social worker dated 9/6/10, "Patient refused to sign". The forms were confusing as to dates signed and who actually participated in the development of the treatment plan or changed the diagnoses problems. There was no change made to the goals.

The treatment goals and interventions are preprinted forms with the problem identified. The date on the form was documented as 8/31/10 with a target date of 9/6/10 as all of the problems listed on the Interdisciplinary Treatment Plan form. The review held 7 days later on 9/6/10 continued the goals another 7 days.

In response to written questions from the surveyor 9/16/10 at 3:15 PM, Employee Identifier (EI) # 1, the Program Director, was asked why the goals were never addressed as met. EI # 1 stated that patients do not ever meet their goals, they just get them to the point they can send them back wherever they were prior to hospitalization.

MR # 2's Graphic Record recorded the percent of each meal consumed by the patient. The patient had a noted change in intake starting 9/10/10, the following is the amount of meal consumption:
9/10/10- Breakfast- 20%, Lunch- 40%, Dinner- 5%, snack was marked NA ( not applicable) on 7-3 and 3-11 shifts.
9/11/10- Breakfast- 0%, Lunch- 0%, Dinner- 0%, snack was marked 0 on 7-3 and a line drawn through the area on 3-11 shifts.
9/12/10- Breakfast- 0%, Lunch- 0%, Dinner- 0%, snack was marked 0 on 7-3 and 0 on 3-11 shifts.
9/13/10- Breakfast- 0%, Lunch- 0%, Dinner- 0%, snack was marked 0 on 7-3 and 0 on 3-11 shifts.
9/14/10- Breakfast- 20%, Lunch- 0%, Dinner- 0%, snack was marked NA (not applicable) on 7-3 and 0 on 3-11 shifts.
9/15/10- Breakfast- 0%, Lunch- 0%, Dinner- 0%, snack was marked NA (not applicable) on 7-3 and 0 on 3-11 shifts.

The patient was observed sleeping by the surveyor 9/14/10 and 9/15/10 in her room. On 9/16/10 she was up in her chair in the group room and continued to be very drowsy.

The physician progress note dated 9/14/10 documented, "Pt.(patient) continues to be very drowsy... may eventually be weaned off everything." On 9/17/10 the physician had placed all medications on hold except for the antibiotics. The patient was observed sleeping in her room by the surveyor 9/17/10 at 9:00 AM.
The weight of the patient on admission, 8/31/10, was 157 pounds. The weight 9/12/10 was 153.5 pounds, there was no other weight recorded in the medical record reviewed by the surveyor. The staff are to weigh the patients every Sunday according to the Administrative Assistant.

There was no change to the problem list, goals or interventions on the treatment plan with the change in the patient from 9/10/10 through 9/17/10 although the Interdisciplinary Treatment Plan update form was in the medical record and dated 9/13/10.

2. MR # 1 was admitted to the Senior Care unit 9/10/10 with diagnoses of Depression and Psychosis.

The Psychiatric Evaluation and the Activity Assessment was completed 9/13/10. The Psychosocial Assessment was signed by the social worker but not dated. A family contact on the form was dated 9/15/10.

The Interdisciplinary Treatment Plan in the medical record was dated 9/10/10. The plan was signed by the Psychiatrist, Social Worker, Activity Director, the Program Director, the RN (Registered Nurse) Manager, the RN who completed the admission assessment and a Licensed Practical Nurse (LPN) case manager.

The diagnosis on the form included: Depression with Psychosis, there was no Axis diagnosis on the form.
The active problem list- psychiatric:
1. Depression
2. Psychosis
3. Anxiety
The active problem list- medical:
4. Hypothyroidism
5. GERD
6. Hyperlipidemia
7. Risk for falls
8. Risk for impaired skin integrity.

There were no dates by the problem list diagnoses documented.

The Preliminary Discharge Plan was left blank, no discharge information was completed and no estimated length of stay was documented.
The area of Patient/Family involvement was signed by the patient and dated 9/10/10.

The treatment goals and interventions are preprinted forms for the problem identified. The date on the form was documented as 9/10/10 with a target date of 9/13/10 as were all of the problems listed on the Interdisciplinary Treatment Plan form. The review held 7 days later on 9/13/10 documented to continue the goals until 9/20/10, another 7 days.

There were no changes made to the original forms completed on the date of admission by the registered nurse. There were no changes made by the social worker, activity director or psychiatrist after evaluating the patient.

In response to written questions from the surveyor 9/16/10 at 3:30 PM Employee Identifier (EI) # 1, the Program Director, was asked how the Interdisciplinary Treatment Plan was developed the day of admission when the Psychiatrist and Activity Director evaluated the patient 3 days later and the social worker assessed the patient on an unknown date. EI # 1 stated that the staff all sign the form to show agreement with the nurses assessment.

3. MR # 4 was admitted to the Senior Care unit 5/19/10 with diagnosis of Bipolar Affective Disorder.

The Psychiatric Evaluation and the Psychosocial Assessment was completed 5/20/10 by a case manager and co-signed by the social worker.

The Interdisciplinary Treatment Plan in the medical record was dated 5/20/10. The plan was signed by the Psychiatrist, Social Worker,the RN who completed the admission assessment and a case manager and was only dated by the case manager for 5/20/10. There was no documentation the activity director attended or participated in the development of the Treatment Plan.

The diagnoses on the form included Bipolar, Manic acute, General Anxiety Disorder:
Axis I: Bipolar anxiety
Axis II: None
Axis III: GERD (gastro-esophageal reflux disease),HTN (hypertension), Hypothyroidism, Hypercholesterol
Axis IV: Severe
Axis V: 15.

The active problem list- psychiatric:
1. Bipolar, Manic (acute manic state)
2. Generalized Anxiety Disorder
The active problem list- medical:
3. HTN
4. Hypothyroidism
5. COPD (chronic obstructive pulmonary disease)
6. CAD (coronary artery disease)
7. UTI (urinary tract infection)

The Preliminary Discharge Plan was marked return to previous living arrangement. The estimated length of stay was 10-14 days.
The area of Patient/Family involvement had documentation the patient adamantly refused to sign and was on court hold.

The treatment goals and interventions are preprinted forms with the problem identified date on the form documented as 5/19/10 with a target date of 5/24/10 as were all of the problems listed on the Interdisciplinary Treatment Plan form. The review held on 5/24/10 continued the goals until 5/31/10.

The patient remained in the facility until 6/22/10 with no changes made to the treatment plan, goals or interventions.

4. MR # 12 was admitted to the Senior Care unit 6/4/10 with diagnosis of Bipolar Disorder.

The Psychiatric Evaluation was completed 6/5/10.

The Interdisciplinary Treatment Plan in the medical record was dated 6/4/10. The plan was signed by the Psychiatrist, Social Worker,the RN who completed the admission assessment, Activity Director and a case manager. It was only dated by the case manager for 6/4/10 and by a RN for 6/7/10. The patient signed the form 6/4/10.

The diagnosis on the form included Bipolar mixed:
Axis I: Bipolar depressed with psychotic features
Axis II: Dependent Traits
Axis III: Hypothyroidism, Degenerative Disc, HX (history) of CVA (cerebral vascular accident)
Axis IV: Severe
Axis V: 20.

The active problem list- psychiatric:
1. Bipolar depressed with psychotic features
The active problem list- medical:
2. Hypothyroidism
3. HX of CVA
4. Seizure disorder
5. Hypercholesterolemia
6. Constipation

The Preliminary Discharge Plan was blank. The estimated length of stay was 7 days.

The treatment goals and interventions are preprinted forms with the problem identified. The date on the form was documented as 6/4/10 with a target date of 6/7/10 as were all of the problems listed on the Interdisciplinary Treatment Plan form. The review held on 6/7/10 continued the goals until 6/14/10 and then until 6/21/10. The patient was discharged 6/17/10, no change was made to her treatment plan while she was hospitalized.

In response to written questions from the surveyor 9/16/10 at 3:40 PM, Employee Identifier (EI) # 1, the Program Director, was asked if the goals were individualized on the treatment plans. She stated," No."

5. MR # 3 was admitted to the Senior Care unit 7/20/10 with a diagnosis of Dementia with Behavioral Disturbances.

A dietitian referral was made on admission due to the patient being malnourished. There was no documentation in the medical record that the dietitian ever saw the patient.

MR # 3's Graphic Record recorded the percent of each meal consumed by the patient. The following is the amount of meal consumption:
7/24/10- Breakfast- 20%, Lunch- 25%, Dinner- 75%, snack was marked 100% on 7-3 and 0 on 3-11 shifts.
7/25/10- Breakfast- 0%, Lunch- 75%, Dinner- 25%, snack was marked NA on 7-3 and 0 on 3-11 shifts.
7/26/10- Breakfast- 20%, Lunch- 5%, Dinner- 70%, snack was marked NA on 7-3 and NA on 3-11 shifts.
7/27/10- Breakfast- 20%, Lunch- 10%, Dinner- 5%, snack was marked 100% on 7-3 and NA on 3-11 shifts.
7/30/10- Breakfast- 0%, Lunch- 0%, Dinner- 0%, snack was marked 0 on 7-3 and 0 on 3-11 shifts.
7/31/10- Breakfast- 10%, Lunch- 50%, Dinner- 0%, snack was marked 0 on 7-3 and NA on 3-11 shifts.
8/01/10- Breakfast- 75%, Lunch- 40%, Dinner- 15%, snack was marked 0 on 7-3 and NA on 3-11 shifts.
8/02/10- Breakfast- 5%, Lunch- 10%, Dinner- 0%, snack was marked 0 on 7-3 and 0 on 3-11 shifts.
The patient was discharged 8/3/10.

In response to written questions from the surveyor 9/16/10 at 3:40 PM, Employee Identifier (EI) # 1, the Program Director, was asked if the dietitian ever visited the patient. She stated no, but that the physician was aware of the patient's poor appetite.

There were no updates or changes made to MR # 3's treatment plan.

6. MR # 6 was admitted to the Senior Care unit on 6/8/10 with a diagnosis of Psychosis NOS.

The Psychiatric Evaluation was completed 6/9/10.

The Interdisciplinary Treatment Plan in the medical record was dated 6/8/10. The plan was signed by the Psychiatrist, Social Worker,the RN who completed the admission assessment, Activity Director, Program Director and a case manager. It was only dated by the case manager and Program Director for 6/8/10. The patient signed the form 6/8/10.

The diagnosis on the form included Dementia:
Axis I: Psychosis NOS, Cognitive Disorder NOS
Axis II: Negative
Axis III: Parkinson's, GERD, HX of TIA (transient ischemic attack)
Axis IV: Severe
Axis V: 30.

The active problem list- psychiatric:
1. Psychosis NOS, Cognitive Disorder NOS

The active problem list- medical:
2. Parkinson's
3. GERD
4. HX of TIA

The treatment goals and interventions are preprinted forms with the problem identified date on the form documented as 6/8/10 with a target date of 6/14/10 as were all of the problems listed on the Interdisciplinary Treatment Plan form. The review held on 6/14/10 documented to continue the goals until 6/21/10.

The patient eloped from the Senior Care unit 6/24/10 and was found on another floor of the hospital. The treatment plan was not revised and the patient was discharged 6/25/10 with his wife.

In response to written questions from the surveyor 9/16/10 at 3:40 PM, Employee Identifier (EI) # 1, the Program Director, was asked if the patient was placed on 1:1 observation when returned to the floor and if the treatment plan was changed. She stated that they did not do 1:1 every patient was on every 15 minute checks and he went home the next day.



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7. Medical Record (MR) # 10 was admitted to the hospital on 6/09/10 with diagnoses to include Dementia with Behavioral Disturbances.

The Mini-Mental Status Examination dated 6/10/10 gave a total score of 2, indicating severe dementia. The Psychosocial Assessment dated 6/10/10 documented MR # 10 had been in the Senior Care Unit (SCU) the week before this admission. MR # 10 was assessed to currently not be able to read or write, lacked insight, had impaired judgement and was hearing impaired.

A review of the nursing assessment documented MR # 10 had impaired speech and was hard of hearing. He wore glasses and hearing aids.

The Interdisciplinary Treatment Plan dated 6/09/10 documented under the active problem list Dementia with Behavior Disturbances, Dementia with psychosis. Under the section titled preliminary discharge plan it was documented, "Patient likely at baseline." There were only two signatures from SCU staff on the document, the Social Worker and Case Manager. There was no date when the Social Worker signed the document.

A review of the care plan for Dementia listed interventions that included:
a. instruct patient on disease process and S & S (signs and symptoms) of increased dementia.
b. instruct patient on need for medication and actions/side effects and scheduling of medications used to treat delirium.

A review of the care plan for Coronary Artery Disease (CAD) listed interventions that included:
a. instruct in cardiac diet as ordered.
b. instruct on S & S of exacerbation of cardiac illness.
c. instruct on measures to assist in management of cardiac illness.

A review of the care plan for Gastroesophageal Reflux Disease listed interventions that included:
a. instruct on actions, scheduling, and SE (side effects) of anti-reflux medications.

A review of the care plan for Benign Prostatic Hypertension listed interventions that included:
a. instruct patient to inform staff of painful urination in order to keep pain under control and assess progress of treatment.
b. instruct patient to inform staff of urination frequency and amount in order to measure progress of treatment.

Care plan interventions were not individualized or appropriate for MR # 10 based on his assessment and past medical history.

8. Medical Record # 7 was admitted to the hospital on 8/24/10 with diagnoses to include Dementia with behavioral disturbances.

A review of the treatment goals and interventions for Benign Prostatic Hypertension, Neuropathy, Dementia, MRSA (Methicillin-Resistant Staphylococcus Aureus), Osteoarthritis, Alteration in Cardic Status, Anemia and Potential for Impaired Skin Integrity related to incontinence and immobility were not individualized or appropriate interventions for a patient with Dementia. None of the care plan goals were documented as met.

A review of the weights obtained from admission to 9/12/10 documented the patient went from 242.5 pounds to 238.5 pounds, a 4 pound weight loss. There was no documentation of changes or updates to his care plan or documentation in the medical record to address his weight loss.

Based on a review of medical records, hospital policy and procedures and interview with administrative staff it was determined the Senior Care Unit failed to:

1. Provide a safe environment for a suicidal patient and a wandering dementia patient.
2. Assure photographs of patients are not taken in a common area.
3. Assure appropriate training is provided to staff to ensure safety in handling patient behaviors.

This had the potential to affect all patients served by the Senior Care unit and affected Medical Record (MR) numbers 6, 9 and 12.

Findings include:

Policy: Elopement
Revised 4/26/10

Policy: To provide for patient safety and to insure the continuation of the patients; treatment program, it is the policy of the Senior Care unit that all patients will be assessed for elopement risk.

Procedure:
1.0- All patients admitted to the Senior Care unit will be assessed for elopement risk.
2.4- Patients who are confused and disoriented or have a history of wandering behavior.
10.0- Elopement risk should be added to the patient's treatment plan along with the interventions being used both to prevent elopement and to explore with the patient the reasons for wanting to leave without completing treatment.
12.0- Nursing should document shift the status of elopement precautions and measures taken to monitor the patient.
18.0- To prevent elopement staff must be aware at all times of who is entering and leaving the unit. Other staff than Senior Care staff that enter on a regular basis should be given instruction on safety regarding the doors to the unit and the use of keys.

Policy: Plan for Staff Education
Revised: April 26, 2010
I. Introduction and Overview:
Sunrise Healthcare Management provides a comprehensive plan for staff orientation and education specific to the care of the adult geriatric patient with mental health problems. This is done with the understanding that individual staff members may or may not have previous psychiatric experience, taking into consideration the differences between this type of patient care and care rendered in the practice of routine hospital medicine.
Orientation is a planned activity with requirements designed to meet competency in working with adult geriatric patients.

II. Orientation:
All Sunrise Healthcare Management employees working at the Dekalb Baptist Medical Center (Dekalb Regional Medical Center) will attend the two day orientation program required by Dekalb Baptist Medical Center. In addition sixteen hours of psychiatric specific orientation in a classroom setting will be completed as part of orientation. Eight hours of this time will be spent in obtaining certification in Non-Violent Crisis Intervention.

III. Ongoing Staff Development
Ongoing staff training is twofold. Topics for educational activities are taught on at least a yearly basis and are considered mandatory for all staff engaged in the direct care of the patient.
1.0- All staff will participate in the following in-service education yearly, and these are considered mandatory in-services.
1.1 Non-violent crisis intervention and use of seclusion and restraint.

Medical Record Findings:

1. Medical Record (MR) # 6 was admitted to the Senior Care unit on 6/8/10 with a diagnosis of Psychosis NOS ( not otherwise specified).

The patient eloped from the Senior Care unit 6/24/10 and was found on another floor of the hospital. The treatment plan was not revised and the patient was discharged 6/25/10 with his wife.

The discharge summary dictated by the Program Director and co-signed by the Medical Director documented the hospital course," Upon admission to the Senior Care unit the patient was extremely confused and anxious, resistant to care, had wandering behavior, difficult to redirect... The patient began to respond to the medication adjustment and had less wandering behavior..."

On the Chronological PRN (as needed) Medication sheet dated 6/15/10 at 2230 the nurse documented, " Very delusional. Talking con't (continuously) to things. Confused about place and time. Wandering halls continuously."

On the Senior Care unit nurse note dated 6/16/10 at 0500 the nurse documented, "... redirect pt. to situation, assess reason for pacing... PRN given continue to observe MD (medical doctor) aware."

On the Senior Care unit nurse note dated 6/16/10 at 1500 the nurse documented, " Poor impulse control, intrusive, pacing excessively, worried...observe for increased behaviors, make MD aware."

On the Senior Care unit nurse note dated 6/24/10 at 1620 the nurse documented, " Attempts to elope. Intrusive...Difficult to redirect cont. behaviors denied any pain or discomfort... MD aware."

On the Senior Care unit nurse note dated 6/24/10 at 1620 the nurse documented," Pt. was wandering about the unit unable to redirect, at one point he wandered off the unit. Pt was quickly returned back to the unit. Pt was redirected to situation but is difficult to redirect..."

On the Senior Care unit nurse note dated 6/24/10 at 2330 the nurse documented, " Pt wanders halls and appears very tired but does not sit long..."

On the Senior Care unit nurse note dated 6/25/10 at 1535 the nurse documented, " Pt was discharged to home... Pt was discharged per wife request."

There was no discharge order in the medical record.

There was no documentation the patient's family was notified he left the secure unit or that the physician was notified he actually left the secure unit and went to another floor of the hospital in the nurse notes.

A narrative attached to the incident report completed by the hospital Director of Risk Management who actually observed the patient on the second floor of the hospital and escorted him back to the unit documented, "... Staff on SCU (senior care unit) were unaware patient had eloped. On arrival to the SCU, staff informed me ' he probably walked out the main entrance doors as visitors were exiting'. They were concerned about the delay in closure of the main entrance doors. Additionally, they informed me the new doors leading to Director's office 'is not working'. I questioned them 'what do you mean they are not working?' They informed me the doors had not been locking properly and yesterday maintenance had worked on them and thought they were repaired. I informed staff we must be certain they are locking and until we know they are working properly a security person must be posted to make sure no patient goes down the stairwell..."

In response to a request for the work order where the doors had been worked on 6/23/10 information was received by fax 9/21/10. The information documented, " Our Facilities Management Director has reviewed all work orders and what we find is that the doors to the SCU had to be 'reset' on the 21st and the work order is enclosed as well as the work order from the 25th when our facilities manager notified..., the contract company for repair of the door."

The doors were repaired by 6/25/10 according to the maintenance department.

In response to written questions from the surveyor 9/16/10 at 3:40 PM, Employee Identifier (EI) # 1, the Program Director, was asked if the patient was placed on 1:1 observation when returned to the floor and if the treatment plan was changed. She stated that they did not do 1:1 every patient was on every 15 minute checks and he went home the next day. EI # 1 was asked if the physician and spouse were notified of the elopement. EI # 1 stated that she notified them but did not document it in the medical record.

The patient exhibited wandering and exit seeking behavior from the time of admission. He was not appropriately managed by the staff on the Senior Care unit and eloped out of the secure unit to an unsecured area of the hospital on another floor.

2. MR # 12 was admitted to the Senior Care unit 6/4/10 with diagnosis of Bipolar Disorder.

The patient was discharged 6/17/10. A photograph of the healed wound was taken in the group room as evidenced by the appearance of a male patient in the photograph. The female patient and the male patient's confidentiality, dignity and respect was not maintained by staff.

In response to written questions from the surveyor 9/16/10 at 3:40 PM Employee Identifier (EI) # 1, the Program Director, was asked why a picture of the patient was taken in the group room. EI # 1 stated that they normally take them back to their room for any photographs.

The surveyors requested a current list of employees with date of hire. The surveyor observed 26 employees had been hired since January 2010. The Program Director provided a list to the surveyors of which employees were trained in CPI (Crisis Prevention Institute). Of the 26 new employees 23 did not have CPI training according to the information provided. The list also noted the expiration dates of employees trained in CPI. 11 of the employees had not received an update to the training. The Senior Care unit employee list included 50 current employees and 37 of these did not have current CPI training.

Nonviolent Crisis Intervention is a program provided by Crisis Prevention Institute. A person is trained to become an instructor in this program after 3 days of education and then is certified to provide training to staff to de-escalate patient behaviors in a safe environment for the patients and staff.

During an interview with EI # 3, the Regional Clinical Director, on 9/16/10 at 2:05 PM she was asked if the staff should be working on the floor without CPI training. EI # 3 responded, "Everybody should be trained before they hit the floor."


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Hospital policy: Suicide Precautions

Procedure:
2.0 Staff member will advise all members of the nursing staff and treatment plan of the patient's status.

3.0 Two staff members will go with the patient to search the patient's room and personal belongings. Potentially dangerous items will be removed.

8.0 Documentation:

8.4.5 Change in affect

8.4.7 Suspicious behavior of any kind

8.4.9 Patient searched and environment and belongings checked for sharps/potential dangerous objects. Document every 8 hours.


3. Medical Record # 9 was admitted to the hospital on 7/6/10 with diagnoses to include Chronic Post Traumatic Stress Disorder and Depression with psychotic features and anxiety.

A review of the nursing notes for 7/7/10 at 8:30 AM documented, "Patient making passive death wish...Pt (patient) states 'I just want to die. Who wants to live like this in constant pain.'...Continue to observe. MD (Medical Doctor) aware. Safety protocol in place." At 12:00 Noon on 7/7/10 the nurse documented, "Isolated and withdrawn...Continue to observe." There was no other documentation by the nurse for 7/7/10 after this entry. A review of the physician orders for MR # 9 revealed that on 7/7/10 at 1:00 PM, the day after admission, suicide precautions were discontinued.

A review of the physician progress note dated 7/7/10 at 12:00 Noon documented MR # 9's status as depressed mood, suicidal ideation, anhedonia, tearfulness, anxiety, withdrawal/isolation and irritable mood. In the narrative section of the physician progress note he documented severe chronic and acute depression.

A review of the physician progress note dated 7/8/10 at 6:30 PM documented MR # 9's status was depressed, bizarre ideas and irritable mood. In the narrative section of the note the physician documented she had poor insight and has flashbacks of watching her mother die.

A review of the nursing note dated 7/11/10 documented at 6:00 PM MR # 9, "...reports she wishes she was dead. When asked about a plan she verbalizes desire to jump off building or throw herself down stairs. 'But I (MR # 9 speaking) will have to be sure there's enough stairs or I will just injure myself.'" MR # 9 was placed in a room close to the nurses desk and was monitored every 15 minutes. It was documented in the nurse narrative that the physician was notified. There were no more nurse entries after this one for 7/11/10.

A review of the physician progress note dated 7/12/10 at 3:45 PM documented MR # 9's status was depressed, paranoid and suicidal ideation were improved, having bizarre ideas, hopelessness and anxiety. In the narrative section of the note the physician documented MR # 9 was having more depression and suicidal thoughts and she needed the addition of an antidepressant.

On 7/12/10 at 6:00 PM there was a physician order to place MR # 9 back on suicide precautions.

The 7/12/10 nurse assessment documented MR # 9 had suicidal ideations during the day shift and passive death wish with a safety plan in place on the nightshift.

On 7/13/10 the nurse documented in the narrative section of her note, no time indicated, that MR # 9 was argumentative and agitated with poor impulse control. Interventions used were to have the patient sit in the day room to calm down. MR # 9 fell asleep and, "...woke up a short time later more agitated." The nurse then administered Ativan, the patient went to bed and slept. On 7/13/10 at 10:00 AM the nurse documented that MR # 9 was intrusive, argumentative and agitated. Interventions used by the nurse were to distract with activities and the result that intervention documented that MR # 9 was, "uncooperative."

There was no physician progress note for 7/13/10 for review in the medical record.

On 7/14/10 there was a physician order, no time documented when it was written, to discontinue suicide precautions. The physician progress note dated 7/14/10 and timed at 12:00 Noon documented MR # 9's status was depressed mood, paranoid ideation, bizarre ideas, tearfulness, grandiosity, anxiety and irritable mood. The narrative section of the physician progress note documented MR # 9 was unstable, labile "but seems improved over all."

The nursing assessment and notes for 7/14/10 documented MR # 9 had suicidal ideations on both day and night shifts. The day shift note, no specific time given, documented MR # 9's behaviors as, "Poor impulse control. Agitation. Yelling, pacing, hyperverbal." The interventions documented were, "Attempted to redirect verbally, distract with activity."

At 4:30 PM the nurse documented in the narrative section of her note, "Pt (patient) found in room in bed (with) bed sheet tied tightly around her neck. Eyes were closed. Resp (respirations) even & non-labored. Pt awoke as we untied the sheet. States she wasn't trying to kill herself. VSS (Vital Signs Stable) NADN (No Acute Distress Noted). Pt brought to nurses desk to sit in chair...All linen & personal articles removed from patient's room. Pt made safe...Pt placed again on suicide precautions."

A review of the physician orders revealed there was an order to place MR # 9 back on suicide precautions at 4:30 PM, after she was found in her room by staff with a bed sheet tied tightly around her neck.

A review of the event report for this incident, completed on 7/15/10 at 5:00 PM, documented MR # 9 was found with a towel, not a bed sheet, tied around her neck and that all suicide precautions in place. The suicide precautions were discontinued by the physician earlier on 7/14/10 after the physician made rounds at 12:00 Noon. There was no documentation that MR # 9 was kept safe and was on suicide precautions at the time she was found in her room with a towel or bed sheet tied tightly around her neck.

Medical Record # 9 was discharged on 7/15/10 to a mental health hospital. The hospital failed to follow it's own policy for suicide precautions and assure that all appropriate safety measures were in place and the environment was safe so as to prevent MR # 9, who was assessed by the physician and nurse as being depressed and having suicidal ideations, from harming herself.

Based on record review, policy and procedure and interview the hospital failed to assure that all medical record entries were dated, timed and reflected the care that was provided to 6 of 12 medical records. This had the potential to affect all patients served and affected Medical Record numbers 2, 6, 7, 9, 10 and 11.

Findings include:

Policy: Multidisciplinary Documentation
Revised: April 26,2010

Policy:
It is the policy of all clinical staff to communicate regarding the patient's status and course of treatment via the medical record on a routine basis throughout the patient's treatment.

Procedure:
1.0- Nursing
1.1- Nursing staff will document in the medical record during the day and evening shift on every patient. Documentation for the night shift will occur when significant events occur.
1.2- RN (Registered Nurse) staff will reassess all patients at least once every 24 hours and more often if warranted.
1.2.1- This reassessment will be demonstrated through the daily notes completed on the day and evening shifts.
1.2.2- Specific events will always be assess and documented by an RN. These are:
(1) Significant changes in patient status- behavioral, emotional, or physical, and actions taken in these cases...
(4) Initiation of precautionary area.

2.0 Social Service
2.2 In addition, Social Service will chart the following on a regular basis on each patient:
2.2.1- Discharge planning information as this plan is formulated.
2.2.2- Treatment planning information as this plan is updated

Policy titled: Physician Orders
Effective: 1/1/1997

4. The physician's orders must be written clearly, legibly and completely.

Medical Record Examples:

1. Medical Record (MR) # 10 was admitted to the hospital on 6/09/10 with diagnoses to include Dementia with Behavioral Disturbances.

The physician wrote an order for the patient to have a Foley catheter on 6/16/10. There was no documentation in the medical record of the Foley catheter being placed or an order to not place the Foley catheter. The 6/17/10 Registered Nurse (RN) note documented that the patient had a condom catheter in place, there was no order for a condom catheter.

The Interdisciplinary Treatment Plan dated 6/09/10 documented under the active problem list, Dementia with Behavior Disturbances and Dementia with psychosis. Under the section titled preliminary discharge plan it was documented, "Patient likely at baseline." There were only two signatures from Senior Care Unit staff on the document, the Social Worker and Case Manager. There was no date when the Social Worker signed the document.

The Pre Admission Screening form has a section for the nurse or social worker to complete with a follow up phone call. The bottom section of the form is not signed, dated or timed by the Registered Nurse (RN).

On 9/16/10 at 4:12 PM, Employee Identifier (EI) # 1, the Program Director, was interviewed and asked about the Foley catheter order and nursing documentation of a condom catheter. EI # 1 stated the Foley catheter could not be placed and there was no documentation of this in the medical record. EI # 1 was asked where staff would document information related to catheters and stated it should be on the narrative section of the nurses notes.

2. Medical Record # 7 was admitted to the hospital on 8/24/10 with diagnoses to include Dementia with behavioral disturbances.

A review of the Activity Therapy Assessment revealed that page 2 of 3 was left blank. No assessment data was documented. On pages 1 and 3 of the assessment it was noted the patient was "unable to answer." There was no documentation of where MR # 7's family or caregivers were contacted to obtain the missing information.

On 9/16/10 at 4:12 PM, EI # 1, the Program Director was interviewed and verified the family should have been asked for the assessment data.

A review of the Social Services notes revealed on 9/3/10 the Social Worker spoke with MR # 10's daughter-in-law and a family session was to be set up. On 9/6/10 the Social Worker documented a family session would be held on 9/9/10 at 1:00 PM. There was no time documented on the 9/6/10 Social Work entry and there was no documentation in the medical record of the family meeting being held.

On 9/16/10 at 3:30 PM, EI # 2, the Nurse Manager, was interviewed and asked about the documentation of the family meeting. EI # 2 stated the social worker was looking for the note on this. No documentation was provided to the surveyor prior to the exit conference.

A review of the Interdisciplinary Treatment Plan dated 8/24/10 had no date of where a Registered Nurse signed the form.

A review of the nursing notes revealed that on 8/29/10 and 9/13/10 only one nurse narrative was documented. In an interview with EI # 2 on 9/16/10 at 3:30 PM it was confirmed each RN should document narrative notes at least once.

A review of the nurse note narrative dated 9/4/10 revealed the RN documented, "Patient confused and uncooperative at times. Difficult to redirect." There was no other descriptive documentation about the patient's behaviors or attempts that were made to redirect MR # 7.

A review of the Discharge Planning Summary in the medical record revealed it was not signed, dated or timed by hospital staff.

3. Medical Record # 11 was admitted to the hospital on 9/05/10 with diagnoses to include Dementia with psychosis.

On 9/15/10 at 8:00 AM the surveyor made observations of the morning group activity. During this observation MR # 11 regurgitated and was removed from the group activity and taken back to her room to have her clothes changed. A review of the group therapy notes for this date documented MR # 11 participated "minimal" for 20 minutes or less. There was no documentation on the activity note or the nursing note of the patient regurgitating and having to be removed from the group activity. The physician progress note did not document the episode and it was not on the Medication Administration Record (MAR). There was documentation on the chronological as needed medication sheet that MR # 11 was given Phenergan for nausea and vomiting.

On 9/16/10 at 3:01 PM, EI # 1 was interviewed about the lack of documentation and stated it was on the chronological and graphic sheet.

A review of the Interdisciplinary Treatment Plan dated 9/5/10 failed to include signature dates for the physician and activity director.

A review of the 9/7/10 communication note for the dietary consult that was ordered failed to document any recommendations for changes or a reason why no recommendations were being made. This entry was not timed as to when it was completed.

4. Medical Record # 9 was admitted to the hospital on 7/6/10 with diagnoses to include Chronic Post Traumatic Stress Disorder and Depression with psychotic features and anxiety.

A review of the 7/12/10 treatment team review was not signed or dated by the physician.

The discharge planning summary was not dated or timed by the RN.

On 7/12/10 the physician wrote an order to place MR # 9 on suicide precautions. A review of the "Close Observation Record" dated 7/13/10 and 7/14/10 failed to document MR # 9 was on close observation for suicide precautions. A review of the nurse narrative for 7/14/10 at 4:30 PM documented that MR # 9 was found in her room with a bedsheet tied "tightly around her neck." A review of the hospital's event report of this incident documented MR # 9 was found with a towel, not a bed sheet, tied around her neck and that all suicide precautions in place. This information is in conflict with the physician's order for 7/14/10 that discontinued the suicide precautions and no documentation on the "Close Observation Record" that MR # 9 was being observed for suicide precautions.

The physician order dated 7/14/10 to discontinue suicide precautions was not timed.

On 9/16/10 at 4:05 PM, EI # 1, the Program Director, was interviewed and asked if staff would document suicide precautions anywhere else in the medical record and verified there was no other place for this to be documented.


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5. MR # 6 was admitted to the hospital on 6/08/10 with diagnoses to include Dementia with Behavioral Disturbances.

The Interdisciplinary Treatment Plan dated 6/08/10 documented under the active problem list Psychosis NOS (not otherwise specified), Cognitive Disorder NOS. There were six signatures from Senior Care Unit staff on the document. There was only two of the signatures with a date, the Case Manager and the Program director.

The Senior Care Unit nurse note documented 6/16/10 at 0500, " PRN (as needed) given."

On 9/16/10 at 3:40 PM, Employee Identifier (EI) # 1, the Program Director, was interviewed and asked what PRN was given to the patient. She stated that she did not know it was not on the Medication Administration Record.

On 6/24/10 at 11:20 the Case Manager documented on the Social Services Activity form, " Talked with ... and advised pt's( patient's) Abilify was increased yesterday and he still is not ready for discharge. Pt needs more time to stabilize. She reports next week is fine..."

On the Senior Care unit nurse note dated 6/24/10 at 1620 the nurse documented, " Pt. was wandering about the unit unable to redirect, at one point he wandered off the unit. Pt was quickly returned back to the unit. Pt was redirected to situation but is difficult to redirect..."

On the Senior Care unit nurse note dated 6/24/10 at 2330 the nurse documented, " Pt wanders halls and appears very tired but does not sit long..."

On the Senior Care unit nurse note dated 6/25/10 at 1535 the nurse documented, "Pt was discharged to home... Pt was discharged per wife request."

There was no discharge order in the medical record.

On 9/16/10 at 3:40 PM, Employee Identifier (EI) # 1, the Program Director, was interviewed and asked if there was a discharge order written or if the physician was notified. She stated that a verbal order was given and it was not documented.


6. MR # 2 was admitted to the hospital on 8/31/10 with a diagnosis of Psychosis NOS.

The patient was observed sleeping by the surveyor 9/14/10 and 9/15/10 in her room, on 9/16/10 she was up in her chair in the group room, continued to be very drowsy.
The physician progress note dated 9/14/10 documented, " Pt.(patient) continues to be very drowsy... may eventually be weaned off everything." On 9/17/10 the physician had placed all medications on hold except for the antibiotics, the patient was observed sleeping in her room by the surveyor 9/17/10 at 9:00 AM.

An Activity note was present in the medical record dated 9/14/10 group time 1600-1700, Current Events or Reminiscing Group- neither was marked.
Participation- Drowsy, Involved in another assigned activity.
Affect- Appropriate
Cognitive- Appropriate
Modes of Intervention- Orientation
Appropriate
The form was signed by a Mental Health Technician.

An Activity note was present in the medical record dated 9/14/10 group time 1830-1900, Evening Wrap Up Group.
Participation- Appropriate, Involved in another assigned activity.
Affect- Appropriate
Cognitive- Confused
Modes of Intervention- Orientation
Successful in achieving short term goal- no.
The form was signed by a Mental Health Technician.

According to documentation in the medical record the patient slept all day.

An Activity note was present in the medical record dated 9/15/10 group time 1600-1700, Reminiscing Group.
Participation- Drowsy, Involved in another assigned activity.
Affect- Appropriate
Cognitive- Confused
Modes of Intervention- Orientation
The form was signed by a Mental Health Technician.
The patient did not attend the group she was observed asleep in the bed at 1600 by the surveyor.

An Activity note was present in the medical record dated 9/15/10 group time 1700, Evening Wrap Up Group.
Participation- Drowsy, Involved in another assigned activity.
Affect- nothing was marked
Cognitive- Confused
Modes of Intervention- Orientation
Successful in achieving short term goal- no.
The form was signed by a Mental Health Technician.

On 9/16/10 at 3:15 PM, Employee Identifier (EI) # 1, the Program Director, was interviewed and asked if the patient had been gotten up and taken to the group room for the activity. She stated no that they should have put she was in bed not marked involved in another activity, that meant that they were somewhere else.