HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 4 patients [Patient #2] had a nursing care plan which addressed [Patient #1's] anorexia diagnosis.

Findings Included:

The medical history and physical dated 05/19/11 reflected, "31 year old female with...history of sexual abuse...serious illnesses, anorexia and post traumatic stress disorder with depression...and suicidal ideations secondary to recent abortion..."

The nursing note dated 05/19/11 timed at 16:30 PM reflected, "Patient on unit, refused to eat dinner...very depressed..." No documentation was found indicating any intervention was provided. No meal consumption percentages were documented for the day.

The nursing note dated 05/26/11 timed at 17:50 PM reflected, "Patient refused to go to dinner..." No documentation was found indicating any intervention was provided. No meal consumption percentages were documented for the day.

On 06/16/11 at 3:30 PM Staff #1 was interviewed. Staff #1 was asked to review [Patient #2's] medical record. Staff #1 stated the care plan did not address [Patient #2's] anorexia diagnosis and refusal to eat some of her meals.

The policy and procedure entitled, "Treatment Planning" with a revision date of 01/11 reflected, "The treatment plan shall identify mental health and physical problems and specify those to be addressed during the treatment episode...the treatment plan will also identify deferred problems with rational for not addressing the deferred problems...interventions shall address physical and functional factors, psychosocial factors, patient/family education, and patient discharge planning..."

Based on interview and record review the hospital failed to ensure nursing personnel administered 2 of 21 scheduled doses of medications for 1 of 4 patients [Patient #2]. The nurse omitted to administer one dose of Abilify 5 mg [Milligrams] po [by mouth] at HS [Hour of Sleep] for 05/23/11 and omitted to administer one dose of Depakote 250 mg BID [Twice Daily] for the 05/25/11 evening dose.

Findings Included:

The medical history and physical dated 05/19/11 reflected, "31 year old female with...history of sexual abuse, anorexia, post traumatic stress disorder with depression and suicidal ideations secondary to recent abortion..."

The physician's orders dated 05/20/11 timed at 17:30 PM reflected, "Abilify 5 mg po at HS."

The medication administration record [MAR] dated 05/23/11 was left blank. The abilify was not initialed as given for the evening dose.

The pharmacy report from the pyxis for all medications administered for [Patient #2] from 05/20/11 to 05/27/11 reflected, no abilify was administered to [Patient #2] on the evening of 05/23/11.

The physician's orders dated 05/24/11 timed at 10:40 AM reflected, "Increase Depakote 250 mg po BID."

The MAR dated 05/25/11 reflected, nursing personnel initialed the Depakote was given to [Patient #2].

The pharmacy report from the pyxis for all medications administered for [Patient #2] from 05/20/11 to 05/27/11 reflected no Depakote was administered for the evening dose on 05/25/11.

On 06/17/11 at approximately 2:00 PM Staff #5 was interviewed. Staff #5 stated she found one omitted dose of Abilify for [Patient #2] for 05/23/11. Staff #5 was asked if she found a second omitted dose for Depakote 250 mg for the evening dose on 05/25/11. Staff #5 stated "No."

The policy and procedure entitled, "Medication Administration" with a review date of 06/10, reflected, "Before the nurse administers the medication, he/she must follow the five rights...right patient, right time, right dose, right medication and right route...the nurse will double check the medication cup after setting up the medications...medications will be checked to the MAR before giving the medication to the patient..."

Based on interview and record review the hospital failed to ensure 1 of 3 patients [Patient #2] had an individualized comprehensive treatment plan which addressed [Patient #2's] anorexia diagnosis.

Findings Included:

The medical history and physical dated 05/19/11 reflected, "31 year old female with...history of sexual abuse...serious illnesses, anorexia and post traumatic stress disorder with depression...and suicidal ideations secondary to recent abortion..."

The nursing note dated 05/19/11 timed at 16:30 PM reflected, "Patient on unit, refused to eat dinner...very depressed..." No documentation was found indicating any intervention was provided. No meal consumption percentages were documented for the day.

The nursing note dated 05/26/11 timed at 17:50 PM reflected, "Patient refused to go to dinner..." No documentation was found indicating any intervention was provided. No meal consumption percentages were documented for the day.

On 06/16/11 at 3:30 PM Staff #1 was interviewed. Staff #1 was asked to review [Patient #2's] medical record. Staff #1 stated the treatment plan did not address [Patient #2's] anorexia diagnosis and refusal to eat some of her meals.

The policy and procedure entitled, "Treatment Planning" with a revision date of 01/11 reflected, "The treatment plan shall identify mental health and physical problems and specify those to be addressed during the treatment episode...the treatment plan will also identify deferred problems with rational for not addressing the deferred problems...interventions shall address physical and functional factors, psychosocial factors, patient/family education, and patient discharge planning..."