HospitalInspections.org

Based on record review and staff interview, the facility failed to assess the care needs and health status/condition of 1 patient [#6] in a sample of 30 patients, who was not eating or drinking enough to maintain his/her nutrition and hydration status.

Findings include:

Patient #6 was admitted to the facility in 1/2015, with diagnoses including psychosis and catatonia.

Review of the policy for Nutrition Assessment last revised on 9/26/13, indicates the following: "A nutritional screen is performed upon admission by nursing and is recorded in the medical record within 48 hours. Documentation is recorded in the nursing assessment section of the chart. If one indicator is triggered on the first section of the screen or two indicators are triggered on the second section of the screen conducted by nursing, the registered dietitian, (R.D.) will conduct an assessment within 72 hours when ordered by a physician."

Review of the admission nursing assessment dated 1/30/15, indicated that the patient was not speaking. The nutritional screen portion of the nursing assessment only indicated that the medical history was unknown and that the appetite was poor. The patient was not eating or drinking but no indicators were triggered on the first and second sections of the nursing nutritional screen. The assessment did not accurately reflect the nutritional issues of this patient. As a result, the nutritional screen assessment failed to trigger for the doctor to order a dietary consult.

On 2/5/15, the patient was sent to the hospital for IV [intravenous] fluids secondary to not taking adequate PO [by mouth] food and liquids. At the hospital, the patient received 1 liter of Normal Saline and 1 liter of Dextrose with Normal Saline.

On 1/12/15 at 10:30 A.M., the Food Service Manager said that the Dietitian did not see the patient because a physician's order had not been obtained.

Based on record review and staff interview, the hospital failed to develop, review, revise and/or implement the care plans for 5 sampled Active Patients (#8, #11, #16, #18, and #19) in of a total sample of 30 Active Patients and for 1 Discharge Patient (#34) and in a total sample of 4 Discharge Patients.

Findings include:

1. For Patient #8, the Hospital failed to have a care plan for this patient's current medical problems, atrial fibrillation and hypertension.

Patient #8 was admitted to the Hospital in 1/2015, with the following pertinent diagnoses; Major depression with catatonia, atrial fibrillation and hypertension.

Review of the Physician's admission problem list indicated this patient had atrial fibrillation and hypertension. The Physician's progress note of 1/31/15, indicated this patient's blood pressure was treated with Lopressor (a beta blocker medication). This Patient's atrial fibrillation was treated with aspirin and Lopressor.

Review of the nursing care plans indicated there was no nursing care plan to address the patient's atrial fibrillation and hypertension.

During an interview on 2/11/15 at 2:45 P.M., Licensed Practical Nurse (LPN) #2 said that there was not a care plan for hypertension or atrial fibrillation.

2. For Patient #11, the Hospital failed to have a care plan for this patient's current medical problem of diabetes mellitus.

Patient #11 was admitted to the Hospital in 2/2015, with the following pertinent diagnoses; Depression, suicidal ideation and diabetes mellitus.

Review of the Physician's admission problem list indicated this patient had diabetes mellitus. The Physician's progress note of 2/4/15, indicated this patient's diabetes mellitus was treated with Invokana, an oral diabetic medication.

Review of the nursing care plans indicated there was no nursing care plan to address the patient's diabetes mellitus.

During an interview on 2/12/15 at 8:10 A.M., the North Clinical Leader said that there was no care plan for diabetes mellitus.

3. For discharged Patient #34, the Hospital failed to have a care plan for this patient's current medical problem of pneumonia.

Discharged Patient #34 was admitted to the Hospital in 2/2015, with the following pertinent diagnoses; Suicidal ideation, opiate abuse and pneumonia.

Review of the Physician's notes of 2/10/15, indicated this Patient was admitted from a community Emergency Department with left lower lobe pneumonia. The physician's orders of 2/10/15, indicated to treat the pneumonia with Azithromycin (an antibiotic) and ProAir (a bronchodilator medication) MDI (metered dose inhaler).

Review of the nursing care plans indicated there was no nursing care plan to address the patient's pneumonia.

During an interview on 2/17/15 at 10:00 A.M., LPN #3 said that there was not a care plan for pneumonia.

4. For Patient #16, the Hospital failed to implement a nursing care plan for the Patient's pain.

Review of the medical record on 2/11/15, indicated Patient #16, had daily complaints of lower back pain, ankle pain, and headaches. During interview at 11:10 A.M. on 2/11/15 the West Unit Clinical Leader said that no nursing care plan for the Patients pain was implemented.

5. For Patient #18, the Hospital failed to develop a nursing care plans for the Patient's knee pain and risk for falls.

Review of the medical record on 2/11/15, indicated Patient #18, was admitted with diagnoses of right knee pain and assessed, on 1/16/15 as a high risk for falls.

During interview on 2/11/15 at 3:15 P.M., the West Clinical Leader said that on 1/16/15 Patient #18 had become very animated in behavior, became irritated and was bumping into walls, and was assessed as a high risk for falls.

However, although a falls care plan was developed, it was not updated. The West Clinical Leader said that after a few days of treatment (no specific date given), Patient #18's behavior changed and the Patient was no longer a falls risk. The West Clinical Leader also said the falls care plan was not updated to reflect that the patient was no longer a risk for falls. The West Clinical Leader said the falls care plan should have been resolved.

The West Clinical Leader also said that a pain care plan was not developed for Patient #18.

6. For Patient #19, the Hospital failed to implement a nursing care plans for the Patient's risk for falls.

Review of the medical record on 2/12/15, indicated Patient #19, was assessed as a moderate risk for falls. A falls care plan that included ensuring the Patient used his/her cane for balance, was developed on 2/10/15.

Observations on 2/11/15 at 3:30 P.M. in the West Unit corridor and 2/12/15 at 9:00 A.M. at the nurses' station, indicated the Patient was walking around the Unit without using his/her cane. During the observation no staff intervened for Patient #19 to use the cane.
















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Based on observation, record review and staff interview, the Hospital failed to administer medications according to the practitioner's orders for 5 Patients, (#1, #10, #15, #18 and #29) out of 30 sampled Patients.
Findings include:

According to the Hospital's policy and procedure on Medication Administration, dated 9/26/14, it read:
- It is the responsibility of all qualified licensed nurses to administer medications as ordered by the physician in a safe and effective manner.
-When administering routine (scheduled) medications, the nurse will follow the 5 Rights System (right patient, right drug, right dose, right time and right route).
-Hold orders are not valid. The medication must be discontinued and reordered.

1. Patient #1 did not receive Novolog 8 units subcutaneous (sc) before breakfast on 2/12/15, as ordered by the physician. Novolog is a fast acting insulin to treat diabetes.

Patient #1 was admitted to the hospital with diagnoses which included dementia with agitation and diabetes.

On 2/12/15, during a medication pass observation at 8:00 A.M., Registered Nurse (RN) #5 was observed administering Lantus (long-acting insulin) 16 units to Patient #1. She did not administer any other insulin at that time.

Patient #1 was observed finishing breakfast at 8:15 A.M.

Review of the clinical record on 2/12/15 at 8:20 A.M., indicated this Patient had a current physician's order to receive Novolog 8 units sc before meals (breakfast, lunch and dinner) at 7:30 A.M., 11:30 A.M., and 4:30 P.M.

On 2/12/15 at 8:30 A.M., RN #5 said she did not give the Novolog as ordered.


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2. For Patient #10, the Hospital failed to perform a dressing change according to the physician's order for discontinuing a topical medication, bacitracin (a topical antibiotic). This was a medication error.

Patient #10 was admitted 2/2015 with the pertinent diagnoses of bipolar illness and frostbite to the feet.

Review of the physician's order of 2/7/15 at 2:40 P.M. indicated there was a new dressing order to wash this patient's bilateral foot wounds with normal saline, pat dry then apply Xerofoam (a petroleum gauze impregnated dressing) and cover with a dry clean dressing with Kling daily (The bacitracin from a previous order had been discontinued in this new order).

During a dressing change on 1/13/15 at 11:50 A.M. with the Surveyor, Licensed Practical Nurse (LPN) #2 performed a dressing charge applying 3 packets of bacitracin to the Xerofoam (an impregnated dressing) and then to the opened areas on this patient's feet.

Interview on 1/13/15 at 3:30 P.M. with LPN #2 and review of the Physician's order of 2/7/15 at 2:40 P.M. and the Treatment Administration Record of 2/2015 indicated the order to discontinue the bacitracin was not followed. LPN #2 said that he should have taken the Treatment Administration Record to the patient's bedside, to check it right before he did the dressing change.



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3. For Patient #15, observation of a medication pass at 11:00 A.M. on 2/11/15, indicated RN #2 failed to follow Hospital policy regarding patient self administration of medication. Observation in the Patient's room, indicated that RN #2 allowed Patient #15 to self-administer the medication Insulin. During interview, back in the medication room at 11:10 A.M., RN #2 said that patients were allowed to self administer medications under supervision.

During interview on 2/11/15 at 12:30 P.M., when queried by the Surveyor, the Director of Performance Improvement said that Hospital policy did not allow patients to self-administer medications.

During interview on 2/12/15 at 9:15 A.M., RN #3 also said that patients were allowed to self-administer medications under RN supervision. After a telephone call with the Assistant Director of Nursing (ADON), at 9:20 A.M. on 2/12/15, RN #3 reported to this Surveyor that the ADON said Hospital policy did not allow patients to self administer medications, even insulin or a creme.

4. For Patient #18, review of physicians' orders on 2/12/15, indicated that Physician #1 and Physician #2 wrote orders and RN #3 accepted orders to hold medications, against Hospital policy.

Physician #1 wrote an order on 1/24/15 at 8:30 A.M., to hold patient #18's 9:00 A.M. dose of Invega and Klonopin.

Physician #2 wrote an order on 1/24/15 at 1:00 P.M., to hold Patient #18's 1:00 P.M. dose of Klonopin.

According to Hospital policy "Hold" orders were not valid and medications must be discontinued and reordered. This did not occur.


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5. Patient #29 did not receive the morning scheduled medications as ordered by the physician on 2/17/15 as the nurse held the medications without an appropriate physician's order.

Patient #29 was admitted to the facility in 2/2015, with diagnoses including paranoia, schizophrenia, hallucinations and suicidal ideation.

On 2/17/15 at 10:00 A.M., review of the medication administration record indicated that on 2/17/15 at 10:00 A.M., the patient did not receive his/her scheduled 9:00 A.M. medications. The medications not administered included the following:
* Propranolol - [a cardiac medication] to be administered BID [2 times a day] at 9:00 A.M. and 9:00 P.M.
* Invega - [an antipsychotic] to be administered BID at 9:00 A.M. and 9:00 P.M.
* Clonidine - [to treat high blood pressure] to be administered TID [3 times a day] at 9:00 A.M., 1:00 P.M. and 9:00 P.M.
* Lamictal - [to treat seizures] to be administered TID at 9:00 A.M., 1:00 P.M. and 9:00 P.M.
* Benzotropine - [to treat tremors] to be administered TID at 9:00 A.M., 1:00 P.M. and 9:00 P.M.
* Wellbutrin - [an antidepressant] to be administered BID at 9:00 A.M. and 9:00 P.M.

Interview on 2/17/15 at 10:15 A.M., Nurse #2 said that the medications had not been given yet. She was holding the medications until the physician sees the patient because the physician might change the medication orders. The nurse also said that she had not received an order to hold the medications. Nurse #2 did not follow policy regarding holding medications.

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Based on record review, observation, and staff interview, the Hospital failed to ensure that 1 of 30 active patient records (#19) and 1 of 4 discharge patient records (#34) had legible Mental Heath Assistant (MHA) notes and Nurse Practitioner (NP) orders. Findings include:

1. For discharge Patient #34, the Hospital failed to have a legible NP order for a follow up Chest-X-Ray (the date for the X-Ray).

Discharge Patient #34 was admitted to the Hospital in 2/2015 with the following pertinent diagnoses; Suicidal ideation, opiate abuse and pneumonia.

Review of the NP's order 2/11/15 at 2:40 P.M., stated that a Chest X-Ray was ordered on 2/18/15 (the number 18 was written over) secondary to pneumonia.

During an interview on 2/17/15 at 10:15 A.M. and review of the Chest X-Ray order of 2/11/15, Licensed Practical Nurse #3, read it aloud and said the Chest X-Ray was ordered for 2/13/15. The Unit Secretary, read it aloud and said the Chest X-Ray was ordered for 2/18/15.

During an interview on 2/17/15 at 10:30 A.M., with NP #1, the Surveyor showed the NP the order of 2/11/15 for the Chest X-Ray. NP #1 said the date of the Chest X-Ray was 2/18/14. She said that she could see that this was a write over and would be sure to write orders that were legible.


2. For Patient #19, medical record review on 2/12/15 indicated that MHA #1's notes written at 8:00 P.M. on 2/11/15 and at 1:50 A.M. on 2/12/15, were illegible.

After being unable to read the above medical record entries, this Surveyor asked both RN #2 and RN #3 to read MHA #1's notes. Both RNs were also unable to decipher what was written.

Based on observation, documentation review and staff interview, the Hospital failed to ensure that all dispensing of drugs by the outpatient staff be under the supervision of a pharmacist in accordance with State and Federal laws.

Findings include:

1. On 2/17/15 at 2:00 P.M., a tour of the Hospital's Outpatient Area revealed a closet containing multiple bottles and packets of samples of the medications Latuda 20 milligrams (mg) and 40 mg, and Invega 3 mg, 6 mg and 9 mg. Additionally, the outpatient Certified Registered Nurse practitioner (CRNP) dispensed multiple sampled medications to patients. Review of the Outpatient service's medication log indicated that all the sampled drugs dispensed to patients were tracked and recorded.

2. Review of the Hospital's policy Pharmacy "Monthly Inspection of Medication Areas" dated 9/30/14, indicated that monthly inspections of all nursing units or other areas of the Hospital where medications were dispensed, administered, or stored would be conducted by a pharmacist or his/her qualified designee.

3. On 2/17/15 at 2:45 P.M., the Hospital Chief Pharmacist said that she was unaware that the Outpatient staff dispensed sampled medications. The Chief Pharmacist also said that she did not maintain oversight of the Outpatient Area and Pharmacy staff did not conduct monthly inspections of the Outpatient Area, as per Hospital policy.

Based on observations and staff interviews, the Hospital failed to ensure that facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. Findings include:

1. During the tour of the West Inpatient Unit on 2/11/15 at 10:30 A.M., the West Clinical Director said that Environmental Services (EVS) staff were required to disinfect the Patient washing machine daily, with a cycle of bleach and document the disinfection. Observation of the Patient Laundry Room, at 10:45 A.M. on 2/11/15, indicated that no disinfection log or schedule of disinfections was found in the room.

During interview on 2/12/15 at 10:15 A.M., the Interim Safety Officer/Director of EVS and the Maintenance Technician also said that 3:00 P.M. to 11:00 P.M. EVS staff were required to clean the washing machine and dryer. The Machine Technician said that EVS did not maintain a disinfection schedule or log for the disinfection of the patients' washing machine. Neither the Interim Safety Officer/Director of EVS or the Maintenance Technician knew when, or if, the patient washing machine had ever been disinfected, as required.

2. Observation of the South Inpatient Unit's Soiled Utility Room on 2/12/15 at 9:45 A.M. indicated a shower chair, cane and laundry hamper stored in the room. The Maintenance Technician said the items were waiting for EVS staff to disinfect them and return them to the Clean Storage Room.

During the observation an Equipment Cleaning Form was noted to be posted on the Soiled Utility Room wall. The Interim Safety Officer/Director of EVS and the Maintenance Technician said as Nursing Staff placed soiled items in the room, then documented the items on the form, as a tracking mechanism. Observation indicated there was no February form and the form observed on the wall was for January and was blank. The Maintenance Technician said that staff did not follow Hospital procedure.

3. Observation of the Soiled Linen Storage Area, for linen waiting pick-up from the contracted laundry company at 9:55 A.M. on 2/12/15, indicated the following:

-The floor was dirty with accumulated dirt, dust and debris;
-Water from the sink was leaking onto the floor. Under the sink was a large build-up of a black substance;
-An air mattress was stored directly on the dirty floor;
-Five pillows were stored on a dirty mop pail. The Maintenance Technician said that the pillows should have been stored in the Soiled Utility Room, awaiting disinfection by EVS staff;
-The utility sink was dirty with black substance and rust; There was no hand washing sink or hand hygiene dispenser in the room.

4. Observation of the Laundry (Mop) Room on 2/12/15 at 10:10 A.M., indicated the following:

-The washing machine drained directly into the utility sink. The inside of the utility sink was black with stains, contained a build-up of lint, dirt and debris from the washing machine water residue, and the drain cover was not covering the drain;

-Inside the washing machine, along the top of the drum, was caked with a build-up of detergent. The sides of the washing machine were dirty with brown and black streaks going down the sides of the machine;

-The sides of the dryer were dirty with brown streaks. The dryer lint screen was overfull with a two inch high build-up of lint, creating a risk for fire.

The Interim Safety Officer/Director of EVS and the Maintenance Technician said EVS staff were required to clean the washing machine and dryer. The Maintenance Technician said that EVS staff did not follow Hospital procedure.

Based on observation, review of Hospital policies and inteviews, the Hospital failed to ensure that policies governing control of infections regarding hand hygiene, disinfection of equipment (glucometer) and overfilling of sharps containers were implemented for 3 (#15, #20 and #25) of 30 Active Patients. Findings include:

Review of the Hospital's Hand Hygiene Policy GP-008 indicated that hand hygiene was to be performed before and after patient contact and after removal of gloves. The policy also referred to Centers for Disease Control and Prevention (CDC) Guidelines for Hand Hygiene which require hand hygiene to be performed prior to donning gloves as well as after glove removal.

1. Observations of medication administration on 2/11/15 at 10:00 A.M. and 11: 30 A.M., indicated that Registered Nurses (RN) #1 and #2, and Licensed Practical Nurse (LPN) #1, failed to adhere to the Hospital's Hand Hygiene and Standard Precautions policies, and the disinfectant solutions manufacturer's directions for use (MDFU), as follows:

a. For Patient #20, observations in the Medication Preparation Room at 10:00 A.M. on 2/11/15, indicated that RN #1 failed to perform hand hygiene after touching the Patient's identification band and prior to administering medications to Patient #20, as required.

b. For Patient #15, observation in the Medication Preparation Room of medication preparation and blood sugar testing, on 2/11/15 at 11:30 A.M., indicated the following:

(On the West Inpatient Unit, patients came to the door of the medication Room to receive their medications. The Medication Room door was made of two sections-upper and lower. The lower section remained closed and locked and medications were administered through the open upper section of the door).

- In preparation to perform a finger stick to obtain Patient #15's blood sugar, RN #2 donned a pair of clean gloves without first performing Hand Hygiene.

- RN #2 then gathered the supplies necessary to perform the finger stick and changed her gloves. RN #2 failed to perform hand hygiene after removing her gloves and prior to donning the clean gloves.

- RN #2 then removed the glucometer (a device that measures blood sugar) from the storage box and turned it on to obtain Patient #15's blood sugar level. RN #2 placed the glucometer and supplies on the shelf of the Medication Room door, next to the Patient.

- RN #2 then picked up the lancet (finger pricking device) and pricked Patient #15's finger to obtain a blood sample. The first stick was unsuccessful.

- RN #2 then obtained another lancet from the clean supply box without first removing her now-contaminated gloves and performing hand hygiene and donning clean gloves.

- Wearing contaminated gloves, RN #2 successfully obtained a blood sample sufficient enough to get a blood sugar reading and picked up the glucometer with contaminated gloves and obtained a blood sugar reading.

- RN #2 then put the now-contaminated glucometer back in the clean storage box without first disinfecting the glucometer, creating a risk of cross-contamination of the clean and/or sterile supplies stored in the box.

- Based on the results of the blood sugar, RN #2 then prepared the medication Insulin to administer to Patient #15. After drawing up the insulin into an insulin syringe, RN #2 used waterless hand hygiene gel (Purell) to disinfect her hands. She wiped some of the Purell off her hands. The MDFU were printed in black lettering on the front of the Purell dispenser indicated "Rub onto hands until dry." RN #2 did not adhere to MDFU of the Purell.

-After administering the Insulin to Patient #15, RN #2 was observed to recap the syringe needle. (Review of the Hospital Policy titled Standard Precautions ISP-001, under the section titled Safe Injection Practices, indicated "Never recap used needles.") RN #2 did not follow Hospital policy regarding recapping of used needles, increasing the risk for a needle-stick injury and transmission of blood borne disease.

3. Review of the disinfectant wipe (PDI Super Sanicloth) MDFU written on the wipe package, indicated that the surface to be disinfected "needed to remain wet for a full two minutes."

For Patient #25, observations in the Medication Preparation Room at 11:30 A.M. on 2/12/15, indicated that LPN #1 touched the Patient's identification band in order to correctly identification Patient #25. LPN #1 created a risk for cross-contamination of the clean glove box when he failed to perform hand hygiene after patient contact. LPN #1 then donned a pair of gloves, without first performing hand hygiene, as required by the Hospital's Hand Hygiene policy.

After obtaining Patient #25's blood glucose reading, LPN #1 wiped the glucometer with a PDI Super Sanicloth. However, LPN did nor ensure that the glucometer was visibly wet for a full two minutes. The glucometer was only wet for 50 seconds. LPN #1 did not follow MDFU.


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4. The Hospital failed to ensure an acceptable level of infection control practice and safety were followed related to over filling 2 sharp containers.

According to the Hospital's policy on Sharps Injury Prevention Disposal of Contaminated Sharps, dated 6/1/2008, it read, "Purpose: To establish work practices which reduce the risk of sharps injuries and subsequent exposure to bloodborne pathogens. After they are used, disposable syringes and needles, scalpel blades and other sharp items shall be placed in puncture-resistant containers for disposal. Responsibility: Unit Nurse/Unit Assistant: Will be responsible for identifying and closing off full container, removing full containers and placing then in the infectious waste receptacle in the dirty utility room for pick up by housekeeping."

a. Observation on 2/11/15 at 10:10 A.M., in the North Unit Medication, Room, with Licensed Practical Nurse (LPN) #2 indicated 2 small sharp containers were filled beyond the full line indicator. Protruding from the containers were 2 razors from one and a syringe from the other.

b. Interview with LPN #2 on 2/11/15 at 10:12 A.M., he said that the sharps containers were in current use, they are brought to the patient's bedside for giving injectable medications and then discarded in these containers. LPN #2 said that the sharps containers were too full. He was aware that the protruding sharps posed a safety risk of a needle stick from a contaminated needle or razor.

Based on record review and interview the Hospital failed to arrange for the post hospital care needs for 1 of 4 discharge patients (#34), for a follow up Chest-X-Ray. Findings include:

Discharge Patient #34 was admitted to the Hospital in 2/2015 with the following pertinent diagnoses; Suicidal ideation, opiate abuse and pneumonia.

Review of the Nurse Practitioner's (NP) order of 2/11/15 at 2:40 P.M., stated that a Chest X-Ray was to be done on 2/18/15, secondary to pneumonia.

Review of the medical record indicated this Patient was discharged on 2/16/15 to a homeless shelter and no Chest X-Ray was done done prior to discharge or scheduled after discharge.

Review of the Discharge Instruction and Information Sheet of 2/16/15 indicated that this Patient did not have an appointment for a follow up Chest X-Ray to evaluate if his/her pneumonia had resolved.

During an interview on 2/17/15 at 10:15 A.M., with the Unit Secretary the Surveyor asked what happened with the Chest X-Ray ordered on 2/11/15 to be done on 2/18/15, for this discharged Patient. The Secretary checked the computer and said since this Patient was discharged she would cancel the Chest X-Ray.

During an interview and review of this Patient's medical chart on 2/17/15 at 10:30 A.M., with NP #1, she said that the follow up Chest X-Ray for this Patient was not ordered as part of his/her discharge appointments but needed to be ordered. She said that she would arrange with the Unit to have the Chest -X-Ray scheduled as a follow up appointment.

Based on medical record review and staff interview it was determined that for four (4) of eight (8) patients the Psychiatric Evaluations failed to include a description of patient assets in a descriptive and not interpretive fashion. The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Patients A3, B1, C1 and C2).

The findings include:

I. Medical Record Review:

1. Patient A3: The Psychiatric Evaluation dated 2/03/2015 had as the only patient asset "He/she is currently co-operative with the nursing staff and not assaultive."

2. Patient B1: The Psychiatric Evaluation dated 1/31/2015 had no description of any patient assets.

3. Patient C1: The Psychiatric Evaluation dated 1/02/2015 had no description of any patient assets.

4. Patient C2: The Psychiatric Evaluation dated 1/02/2015 had no description of any patient assets.

II. Staff Interview:

On 2/10/2015 at 2:30 PM the clinical director was shown the Psychiatric Evaluations cited in Section I. above. She agreed that they lacked an assessment of patient assets.

Based on record review, interviews, and observation, the facility failed to ensure that potentially severe medical problems identified upon admission (Initial Psychiatric Evaluation, Admission Physical Exam, Nursing Admission Assessment and Psychosocial Assessment) for three (3) of eight (8) active sample patients (A1, A2 and A3) were included in the Interdisciplinary Treatment Plan. Specifically, failure to address medical problems results in a potential risk to patients' health and prevents them from achieving an optimal level of functioning.

Findings:

I. Policy review

Whittier Pavilion Policy titled "Interdisciplinary Treatment Team Planning and Meeting" (Policy #TR-01), effective 06/01/08, revised 09/06/12, and reviewed on 08/15/13 states "Information for this plan will be determined based on the following. Standard B #2 Existing medical conditions, #3 Neurological findings, #4 Nursing assessment, #5 Psychosocial Assessment and #6 Safety considerations. Standard D #3 (b) Active medical problems." The facility failed to follow its own policy on the aforementioned.

II. Record Review (findings related to patient medical problems)

Patient A1

1. Psychiatric Evaluation dated 1/8/15 noted a diagnosis of "Major depressive disorder, severe, without psychotic features. Weight loss 25-30 lbs. (pounds) in the past 3 weeks and Hyperlipidemia."

2. Psychosocial Assessment dated 1/9/15 "Increased depression, lost 25-30 lbs. exhibits decreased energy."

3. Nursing Admission Assessment dated 1/8/15 "Depressed mood, decreased appetite, weight 178 lbs. high cholesterol, dry skin, recent weight loss 25-30 lbs. in 3 weeks. Nutritional consult requested, MD (Medical doctor) notified."

4. Admission Physical Exam dated 1/8/18 dated "(L) knee pain occ (occasionally) buckles, Dyslipidemia on statins."

5. The patient's Interdisciplinary Treatment Plan (ITP) dated 1/9/15 and updated 2/2/15 did not address the patient's medical problems.

6. Patient chart review "Nutritional Screening - Regular diet."

7. Order dated 1/9/15 to give patient one can Ensure (supplement) twice a day.

8. Treatment Records from 1/9/15 to 1/21/15 could not be found in A1's medical record or in the MAR (Medication Administration Record) by the RN#1 for validation at this time. Records were found on the following dates in the MAR.

1/22/14 noted on green treatment record patient received Ensure at 08:00 AM and 16:00.

1/23/15 noted on green treatment record patient received Ensure at 16:00.

1/24/15 no entry noted (space/blank) on green treatment record.

1/25/15 no entry noted (space/blank) on the green treatment record.

1/26/15 noted at 16:30 "refused."

1/27/15 no entry noted (space/blank) on the green treatment record.

1/28/15 noted refused at 08:00 AM and 11:30 AM.

1/29/15 noted 08:00 AM and 16:00 refused.

1/30/15 noted 08:00 AM and 11:30 AM refused.

1/31/15 noted 16:30 refused.

2/01/15 noted 16:30 refused.

2/02/15 noted 16:30 refused.

2/03/15 no entry noted (space/blank) on the green treatment record.

9. On 2/04/15 order for Ensure supplement was discontinued by the doctor.

10. Order dated 1/20/15 to weigh patient every Tuesday.

Sample Patient A1's weight on admission (1/8/15) was 178 lbs. As of the dates of survey (2/9/15 to 2/11/15) patient had lost a total of 4 lbs. in approximately 4 weeks.


11. As of date of survey (2/9/15 to 2/11/15) there was no evidence in the patient's (A1) medical record of a Nutritionist Consultation regarding weight loss. In addition, Patient A1 continues to lose weight.

12. Hyperlipidemia - order dated 1/8/15 Atorvastatin 20 mgs p.o. (orally) at bedtime.

13. The Interdisciplinary Treatment Plan had not been updated as of the time of survey (2/9/15 to 2/11/15) to address patient A1's medical problem(s.)


Patient A2:

1. Psychiatric Evaluation dated 1/19/15 noted a diagnosis of "Dementia with behavioral disturbance and anxiety, NOS. Hypertension, coronary artery disease, status post myocardial infarction and CABG (coronary artery bypass graft) hyperlipidemia."

2. Psychosocial Assessment dated 2/14/15 "Family History (Including Constellation, Medical Illness and Substance Abuse Issues)." There was no mention of any medical illness.

3. Nursing Admission Assessment dated 1/19/15 "Anxious, decrease appetite, hypertension, hyperlipidemia."

4. Admission Physical Exam dated 1/20/15 "Hypertension see MAR (medication administration record)."

5. Hypertension - order dated 1/19/15 Metoprolol Tartrate 25 mgs p.o. (orally) twice a day.

6. Hyperlipidemia - order dated 1/19/15 Atorvastatin calcium 40 mgs p.o. (orally) daily.

7. The patient's Interdisciplinary Treatment Plan (ITP) dated 1/19/15 and updated 1/28/15 had not been updated as of the time of survey to address patient A2's medical problem(s).

Patient A3:

1. Psychiatric Evaluation dated 2/3/15 noted a diagnosis of "Dementia Alzheimer's type with behavior problems, aggressive/assaultive. Hyperlipidemia and post hand contracture surgery"

2. Psychosocial Assessment dated 2/4/15 "Alzheimer's dementia and high cholesterol"

3. Nursing Admission Assessment dated 2/3/15 "Aggressive/assaultive, depressed, angry, suspicious and agitated."

4. Admission Physical Exam dated 2/3/15 "Alzheimer's dementia type, dyslipidemia on statins."

5. The patient's Interdisciplinary Treatment Plan (ITP) dated 2/3/15 and updated 2/4/15 had not been updated as of the time of the survey (2/9/15-2/11/15) to address patient A3's medical problem(s).

III. Interviews:

A1: In an interview on 1/10/15 at 11:30 AM with patient, he/she stated that "On the exterior I am fine, but on the interior I don't feel so fine. The food here is fine, but I don't feel like eating much. My left knee bothers me, and I don't know if I can go back to my apartment."

A2: In an interview on 1/10/15 at 10:00 AM with the patient, he/she stated, "I cannot remember what happened, why I came here. I couldn't remember for a week or so. Whatever they did, snapped me out! I want to go home now."

A3: Interview attempted 1/9/15 at 2:30 PM. On 1/10/15 at 11:00 AM "Don't want to talk."

RN#1 (Clinical Leader). In an interview on 1/9/15 at 1:28 PM, the nurse was asked to tell the surveyor about sample patient A1. RN#1 stated that (he/she) had asked for a Nutritionist Consult, but was not "aware that they came." RN#1 did not find any documentation in this patient's medical records under "Consultation" section at this time. When asked about the patient's gait, RN#1 stated " He came in walking like that and he refuses pain medications. "

In an interview on 1/10/15 at 1:30 PM with the Director of Nursing, the Assistant Director of Nursing and RN#1 (Clinical Leader.) all agreed that for 3 of 8 sample patients (A1, A2 and A3.) their Interdisciplinary Treatment Plans did not mention patients' medical problems. The RN#1 stated, "There is none." The Director of Nursing verified that the Treatment Plans for sample patients A1, A2 and A3 did not include patient medical problems.

IV. Observation:

Sample Patient A1 was observed in an exercise group walking with a noticeable left sided limp. RN#1 stated, "He came in walking like that."