HospitalInspections.org

Based on record review of 10 patient charts (P1-P10) and interview the facility failed to include the patient (pt.) or a designated pt. family member/representative in the development or implementation of the patients treatment plan, including the pts. inpatient care and discharge planning in 1 (P3's) chart out of the 10 charts reviewed.. This deficient practice is likely to develop treatment plans that are not effective due to lack of patient or family member/representative's inclusion in the patients care that can likey effect the patient's psychological and medical needs. .

The Findings are:
A. Record review of pt. P3's admission "Psychiatric Evaluation" dated 6/17/20 at 6:09 pm, by the Psychiatrist (MD), on page 3 revealed the following documentation "The patient is not capable of making treatment decisions."

B. Record review of pt. P3's "Admission History and Physical Exam" dated 6/17/20 at 4:11 pm, by the Internal Medicine (Internist) MD, on page 7 revealed: "Attending attestation: I (Dr's name) ... could not discuss her (the pt.) issues with her due to (d/t) severe cognitive impairment."

C. Record review of P3's facility "Face Sheet" (no date) and initial "Psychosocial Assessment" dated 6/17/20 at 1:45 pm both documents reveal that (name of pt's. sister) is designated as the pts. "Health Care Surrogate (HCS)" and listed a contact phone number.

D. Record review of P3's facility "Interdisciplinary Treatment" list of Attendees dated 6/18/20 at 11:00 am reveals no listing (inclusion) of the pt., her HCS, or any other pt. representative being included in P3's treatment planning.

E. Record review of P3's facility "Multidisciplinary Treatment Team Plan (MTTP)" dated 6/16/20 at 11:00 am reveals:
1. Documentation on page (no page #) that "Pt." and "Family" will be included in "Discharge/Continuing care" and specifically has "Medication" and "Nutrition" boxes checked in regards to pt. and family education.

2. Documents on page 5 under "Family/Significant Other Involvement in Treatment Plan (TP)", there is a box checked "No known family".

3. There was no documentation on the "Master Problem List (MPL)" of: Skin Integrity; Infection/UTI's; or Dietary goals/concerns. On 6/22/20 (no time), "Skin" and "Infections (UTI)" were added to the MPL. "Skin" MPL has a box checked to "Educate pt. and family". "Infections (UTI)" left this box unchecked.

F. Record review of P3's facility initial "Psychosocial Assessment" dated 6/17/20 at 1:45 pm on page 8 reveals pts. sister (pt's. sister and HCS) "would like to be communicated with regarding changes in pts. medication and treatment."

G. Record review of P3's facility "Social Service Progress Notes (SSPN)" (form that the Social Workers (SW) document on) reveals that the four notes listed below are the only SW documented communication with the pts. family/HCS or group home:
1. Dated 6/18/20 at 9:15 am documents: "Student Social worker call pts. daughter (incorrect, call was to the pt's sister according to the name documented) regarding surrogate decision maker paperwork. Emailed new sorrogate decision maker form". No other communication is noted.

2. Dated 6/19/20 (no time) documents: "SW will reach out to group home to confirm discharge plan..." There is no further documentation of any contact or conversation being had.

3. Dated 6/22/20 at 6:20 pm documents: "SW left message (LM) for group home to find out if (Covid 19) swab needs to be completed prior to DC (Discharge back to the group home)."

4. Dated 6/23/20 at 11:00 am (the time the pt. was transported via ambulance to another hospital ED (Emergency Dept.)) documents: "SW spoke with (pt's sister's name) to notify her that her sister was going to the ED. SW LM (left message) for group home."

H. Record review of the "Incident Occurrence" form submitted to NM DOH dated 7/8/20 at 9:16 am and completed by the RN (the complainant) of the pts. Developmentally Disabled (DD) Care Management Organization (CMO) states that, in summary: The pt's "physical state within normal limits (WNL- No problems); skin clean, dry and intact (no problems)". RN also writes that several team members called the facility "frequently...to check on (pts. name) status and progress. We were told each time that she was still having some dementia issues and she hadn't wanted to eat or drink." He further writes "(name of one of the CMO team members) received a call from (pt's. name) sister, on 6/24/20 and she stated that (pt's name) was admitted to (name of hospital) with life-threatening issues; kidney failure, severe dehydration..." He further writes "(Facility name) didn't notify (CMO name) of (pt's name) condition prior to transferring her to (name of hospital), though they had our contact information. Nor did they state to (team member's names) that (pt's. name) had seriously declined while at their facility."

I. On 12/23/20 at 9:35 am during phone interview, complainant confirmed the information he had written in the above mention NM DOH "Incident Occurrence". He expressed that his biggest concerns was the major decline in P3's (the pt.) physical health while in the facility. Also mentioned his frustration with the poor, inaccurate communication with facility and the facility's lack of involving his Developmentally Disabled Care Management Organization (DDCMO) team in P3's treatment.

Based on record review of 10 patient charts (P1-P10), interviews and observation the facility failed to ensure that it's patients are free from all forms of neglect in the care of 1 patient (P3). This deficient practice is likely to result in patients not receiving necessary care and places patients at increased risk for mental, emotional and psychological harm, as well as physical harm and pain.

The Findings are:
A. Record review of patient (pt.) P3's (an elderly female) admission Nursing Assessment (NA), dated 06/16/2020 at 1:45 pm revealed the following:

1. A height of 5ft. 3in., a weight of 99.4 pounds (#), and a body mass index (BMI- a measure of healthy vs. unhealthy weight) of 17.6. A BMI less than 18.0 is considered low, and can result in a diagnosis of "Failure to Thrive (FTT)".

2. 1 "bruise" on pt. P3's left elbow and 3 "red spots" on pts. right calf.

3. An oxygen saturation level (O2 sat- a measurement of respiratory and cardiovascular function) of "94% on room air (RA- 90% and above is considered normal). The rest of pts. vital signs (v/s) were normal, except P3's blood pressure appears to be high at 175/70- but it is difficult to read the written documentation (140/90 and above is considered a high b/p).

4. P3's "Functional Screening" of the NA documents pt. as "Total Assistance" in 4 out 5 areas of: Walking, Dressing, Bathing, and Toileting. And "Supervision Needed" for Eating.

5. Pts. "Nutrional Screen" notes the low BMI of 17.6 and "Decreased oral intake, less than 50% of usual intake."

6. A "Falls Assessment Risk Score" of "20" out of a possible 24, and is listed as "High" fall risk. There were 12 listed fall risk interventions, none of which were checked off (implemented), nor is there any note of this "high" fall risk determination in the narrative section of the NA. Also documented in the NA is "Hx (History) of: vertigo/dizziness; lower limb dysfunction; and bowel and bladder incontinence (lack of control of bowel and bladder)", all of which increase P3's risk for falls/injuries and skin integrity problems.

7. On the Nursing Assessment (NA) "Summary/Nursing clinical formulation" (narrative) section the RN (Registered Nurse) documents that P3's "urine was dipped and it dipped + (positive- meaning a possible urinary tract infection (UTI)) and it was scanned to Dr. (Name)." A UA (Urine Analysis) with C & S (Culture and Sensitivity- to detect UTI's) was not ordered by the (same) MD (Medical Doctor) until 6/22/20 at 5:30 pm, along with an MD order to "place foley catheter (a medical tubing and bag to facilitate the pt's ability to urinate and to prevent urinary incontinence (wetting))" All of the above issues identified on the admission NA increase this pt's risk for potential nutritional, injury and skin integrity problems.

B. Record review of patient P3's "Admission History and Physical Exam (H&P)" by the Internal Medicine MD dated 06/17/2020 at 4:11 pm revealed the following:

1. Under Diagnostic Data: Schizophrenia (severe); along with Intellectual disability, seizure disorder, and dysphagia (difficulty swallowing), along with a few other diagnoses. A "regular" diet was ordered, despite these noted issues.

2. On page 7 of the same H&P, the MD further documents "severe cognitive impairment (severely poor mental capability/functioning)" regarding this pt.

3. On page 6 of the H&P, the MD documents "Erratic movements. She (pt.) will be on fall precautions. I will order a bed alarm at night for fall prevention." However, there were no such corresponding orders in the "Physician's Order Sheets".

C. Record review of patient P3's initial "Psychiatric Progress Note" by the Psychiatrist (MD) dated 06/19/20 at 6:35 pm (more than 72 hours after this pt. was admitted to the facility) revealed the following documentation:

1. On page 1: "The patient requires some assistance with her ADL's (Activities of Daily Living- performing personal care, such a hygiene, eating and drinking.)".

2. On page 2: "The patient has been confused. She has been getting agitated at times. She has been banging her head.". "Diagnoses: 1. Major Depression (MD), recurrent, severe. 2. Dementia with behavioral disturbances." "Risk: Current CGI (Clinical Global Impression): Severe".

D. Record review of patient P3's "Psychiatric Progress Note" by the DNP (Doctorate of Nurse Practioner) dated 06/20/20 at 4:19 pm revealed on page 1: "Yes, the patient is unable to tend to ADL's (Activities of Daily Living- performing personal care, such a hygiene, eating and drinking.) and require staff assistance."

E. Record review of patient P3's "Psychiatric Progress Note" by the same Psychiatrist (MD) dated 06/23/20 at 3:58 pm (after the pt. had already been discharged to an acute care hospital ER) revealed the following on page 2: "We will continue with the present treatment plan. We will continue to monitor medications closely and we will continue to assist the patient in getting stabilized and ready to be transferred to a lower level of care."

F. Record review of patient P3's "Skin monitoring: Comprehensive BHT (Behavior Health Technician) Shower Review (Shower Sheets- SS)" revealed the following:

1. SS dated 6/16/20 (no time) documents: "No significant findings.", which is in contradiction to the nursing assessment (NA) documentation done on the same date.

2. SS dated 6/18/20 (no time) documents: "1. Brusing" and "10. Scratches".

3. SS dated 6/21/20 (no time) documents: "10. Scratches" and "15. Other: Pressure (Deep tissue injury)"

4. The body diagrams marking what kind of injury and location do not match up on any of these 3 SS documents or with the admission NA.

G. Record review of patient P3's "Vital Flow Sheets" revealed that the "Food %" portion had been recorded for breakfast, lunch, and dinner for a total of 20 meals during the pts. 7 days at the facility. Of 20 recorded meals, 10 were documented as "0%" or "R (Refused- meaning the pt. refused to eat anything)". Another 6 were "20%" or less. Only 1 (out of 20) meal percentage was listed as greater than 50%.

H. Record review of the "Physician Order Sheets" reveals no orders during her entire stay until 6/23/20 (her d/c to the ER date) for addressing this poor food intake. No MD orders for a change in diet, 1:1 staff feeding, a dietician consult, a swallow evaluation, or any other options or actions.

I. Record review of patient P3's "Daily Nursing Shift Notes" (DNSN's) which are done twice daily (AM's and PM's) for a total 12 DNSN documents revealed the following:

1. 9 of the 12 total DNSN's document "Skin: Intact (No skin problems)" despite skin integrity issues being documented on the admission NA. These documents are also inconsistent with each other and with the "Shower Sheets (SS)" documentation.

2. DNSN dated 6/18/20 at 5:00 pm states "Pt. was found sliding self off bed and onto floor" (repeatedly) and "Dr. (name) called order given." There are several other similar documentations (in this pt's 12 DNSN's) of P3's physically out of control and potentially self injurious behaviors.

3. On 6/18/20 at 1700 there is a TORB (Telephone Order Read Back- Meaning that the MD was not present at the facility to be able to assess the pt. in person) given by the MD for "1. Place pt. on LOS (line of sight) for safety. 2. Place mattress on ground for safety. 3. Bed/chair alarm as needed for safety."
There are no other pt. safety or precautionary MD orders during pts. time at the facility.

4. On 6/20/20 AM shift the DNSN documents the pts. weight as 84.3# (pounds), a slightly more than 15 pound decrease from the documented weight of 99.4# on 6/16/20.

5. On 6/20/20 PM shift the DNSN documents that the pt. is "Total assist with meals and ADL's".

6. On 6/21/20 at 1600 the RN documents "Patient has deep tissue injury in her left shoulder and or (sic) and or both ankles, she need frequent positioning to prevent further skin danger."

7. On 6/21/20 (no time) on "Progress Notes" form it is documented that P3's "oxygen concentration consistently below 90% RA (on room air)...78% (Very low) RA at 7:20 pm...Initiate oxygen 2L (a standard amount/measurement) via N/C (nasal canula- a O2 delivery system using tubing into the nostrils). Please write order...Faxed to Provider."- Staff signature is unreadable and has no title. The provider signed the order on 6/22/20 at 01:20 am for "O2 2-3L per n/c to keep O2 sat > 90%."
This poor oxygenation level is further evidence of P3's deterioration of health status.

8. 3 DNSN's dated 6/21/20-6/23/20 all document skin integrity problems including the "left shoulder, left elbow, both Tronchanter's (Hip areas) and both ankles."
a. The first and only MD order for wound care for P3 is dated on 6/23/20 at 9:50 am as a "TO" (Telephone Order) by the Internal medicine (Internist) MD. Included with this order is "Health shakes TID (3 times a day) to promote healing", which is the first dietary change order since pts. admission 7 days earlier, and only approximately 1 hour before the pt. was discharged to another hospital's ER.

J. On 6/22/20 at 5:30 pm (in response to a DNSN on 6/22/20 at 5:15 pm stating that "Pt. abdomen distended. Hard to touch.") there is the first order, a TORB, relating to possible UTI concerns from the Internist MD to perform a "Straight catheterization (placing a tube into the pts. bladder to release a flow of urine) for distended bladder" and also "UA, C&S- place foley catheter". Of note, this required P3 to be catheterized twice, instead of just once. Catheterization is an invasive (penetrating into the body) and often times uncomfortable procedure.

K. On 12/23/20 at 10:25 am on the non-CV 19 (Covid 19) unit observation of staffing levels was 3 BHT's (Behavior Health Technician's) (+ 1 in orientation) and 2 RN's to care for 20 pts. I observed similar staff and pt. numbers again on 12/24/20 at 9:50am. This is a ratio of approximately (Pts. to Staff) 7:1 for the BHT's and 10:1 for the RN's. This unit consisted of primarily of older/senior pts., whom often require a higher level of monitoring and care than a younger pt. population. Another area Psychiatric Hospital uses staffing ratio's (Pts. to Staff) of 3-4:1 for BHT's and 7-8:1 for RN's on it's Geriatric psychiatric unit.

L. On 12/23/20 at 11:22 am during interview, S2 (CNO) confirmed that the facility (for both units) staffing ratios (Pts. to Staff) are BHT's 7-8:1 and RN's 10-12:1. A high patient to staff ratio can often lead to poor pt. care and problems such as pt. neglect.