HospitalInspections.org

Based on record review and interviews, the facility failed to document individualized short term measurable goals on the Master Treatment Plans (MTP) for 3 of 5 active sample patients (A1, A2 and A4). The short term goals were not measurable patient behaviors. This failure results in Mater Treatment Plans that do not identify expected patient outcomes in a manner that can be utilized by the treatment team to determine the effectiveness of treatment.

Findings include:

Record Review (MTP dates in parentheses)

1. Patient A1: The short term goal on the MTP (7/7/11) was "pt is less anxious." This goal was not measurable.

2. Patient A2: The short term goal on the MTP (7/1/11) was "The patient will learn to coping skills that reduce the chance of relying on self-destructive behavior. The patient will discuss feelings that precipitate violence. Patient will understand illness and tx [treatment]." These goals were not measurable.

3. Patient A4: The short term goal on the MTP (7/5/11) was "The patient will maintain safety and self control with the assistance of staff." This goal was not measurable.

B. Staff Interviews

1. In an interview on 7/19/11 at 9:30AM, the Director of Quality Assurance/Director of Nursing and the Director of Inpatient Services agreed with the above findings. The Director of Inpatient Services stated, "...we need to educate staff so they fully comply with requirements."

2. In an interview on 7/19/11 at 9:30AM, the Director of Quality Assurance/Director of Nursing stated "Our plan of correction date is the month of July and we have completed the training but haven't yet obtained the monitoring as we are still in the month of July."

Based on record review and interviews, the facility failed to develop Master Treatment Plans that clearly delineated staff interventions to address the specific problems of 3 of 5 active sample patients (A1, A2 and A4). The Master Treatment Plans only listed generic tasks instead of identifying discipline-specific interventions/modalities and their frequency of use. This failure results in treatment plans that do not provide guidance to staff in delivering individualized and coordinated treatment for patients.

Findings include:

1. Patient (A1): The Master Treatment Plan developed on 7/7/11 had the following listed interventions: "meds supportive milieu, Medicate patient as ordered, Monitor vital signs."

2. Patient (A2): The Master Treatment Plan developed on 7/1/11 had the following listed interventions: "Collect and search belongings in accordance with hospital policy. Maintain precautions as necessary per hospital policy. Question directly regarding safety issues. Encourage patient to attend appropriate groups to learn new coping methods and problem solving techniques. Nurse will monitor vital signs per physician order."

3. Patient (A4): The Master Treatment Plan developed on 7/5/11 had the following listed interventions: "Collect and search belongings in accordance with hospital policy. Maintain precautions as necessary per hospital policy. Question directly safety issues."

B. Staff Interviews

1. In an interview on 7/19/11 at 9:30AM, the Director of Quality Assurance/Director of Nursing and the Director of Inpatient Services agreed with the above findings. the Director of Inpatient Services stated, "...we need to educate staff so they fully comply with requirements."

Based on record review, staff interview, facility policy and videotape review, the facility failed to assure the Medical Director and Director of Nursing adequately monitored the appropriateness of care provided to a patient (C1) who died on 7/3/11. The facility began a root cause analysis following the death of patient C1, who was found unresponsive in bed by nursing staff at 3a.m. on 7/3/11, and pronounced dead with rigor mortis at 3:16a.m. on 7/3/11. However, the draft of the root cause analysis shown to the surveyor on 7/19/11 did not clearly identify several deficiencies found by the surveyor as problems needing correction. Review of a videotape from the unit where C1 was housed revealed that nursing staff did not properly perform 15 minute patient rounds/checks, and did not begin timely CPR/Code procedures when patient C1 was found unresponsive. Nursing staff were not sufficiently aware of the seriousness of the patient's condition to immediately proceed with CPR/code blue procedures. Although administrative staff acknowledged these deficiencies and stated that they planned to retrain nursing staff on patient rounds/checks and CPR/code blue procedures, at the time of the survey (2 weeks after the patient's death), the retraining had not been scheduled and there was no documentation that any staff had received the retraining. These failures led to an IMMEDIATE JEOPARDY for the facility on 7/19/11 at 2:30p.m., and the Director of Quality Assurance/Director of Nursing and the Director of Inpatient Care were notified of the IJ.


Refer to B144 for the Medical Director's failure ensure the quality of medical services, and refer to B148 for the Director of Nursing's failure to assure adequate nursing care.

Based on record review, videotape review, policy review, and staff interview, it was determined that the Medical Director failed to ensure that a thorough root cause analysis was conducted and documented for the death of Patient C1, who was found unresponsive by nursing staff at 3a.m. on 7/3/11 and pronounced dead with rigor mortis at 3:16a.m. on 7/3/11. A draft of the root cause analysis shown to the surveyor on 7/19/11, two weeks after the patient's death, did not identify staff deficiencies that were noted during the survey. A videotape from the unit where C1 was housed showed that rounds/patient checks were not always completed in a timely and thorough way, and that CPR/code blue procedures were not implemented in a timely manner. The Medical Director also failed to assure that staff retraining was conducted to correct these deficiencies. In addition, there was no evidence that Medical Director had interviewed the doctor on call (DOC) on the night of C1's death, and who responded to the code blue call, concerning the events related to the Patient's C's death (e.g., the DOC's documentation of the patient's "rigor mortis" and the attempted resuscitation procedures. These deficiencies result in an unsafe environment for all patients at the hospital.

Findings include:

A. Record Review

1. Patient (C1) was admitted on 5/12/11 for multiple symptoms of depression and the following diagnoses: "Bipolar I Disorder, Most Recent Episode Depressed, Severe without Psychotic Features, Opioid type dependence continuous, Alcohol abuse in Remission, Cannabis abuse in remission, and Cocaine abuse in remission."

2. The Discharge Summary dated 7/3/11 stated: "On 7/1/11, Mr. X (C1) expressed a better outlook on his circumstances and reported some reduction in depressive symptoms and suicidal ideation. He was in agreement about an ECT series if necessary with the understanding that a short series would avoid severe memory loss. Sadly, in the early morning hours on 7/3/11, Mr. X (C1) was found unresponsive and did not respond to resuscitation."

4. A Progress Note written by the Doctor on Call (DOC) on 7/3/11 at 3:51p.m. stated, "Code Blue was called. On my arrival. pt was lying supine. Pt was cyanotic. No pulse or resp [respirations] present. Pupils - fixed and dilated. Pt was in rigor mortis...CPR was performed. Epinephrine 1mg/IM - given twice. Resuscitation was continued for 15mts. [minutes]. 911 was called. Pt was pronounced dead at 3:16a.m."

B. Videotape Review

On 7/19/11, the surveyor, accompanied by the Director of Quality Assurance/Director of Nursing and the Director for Inpatient Services, viewed a videotape that recorded the rounds/checks for Patient C1 for the dates 7/2/11 (9:43p.m. to 11:48p.m.) and 7/3/11 (12:05a.m. to 3:10a.m.). The following is the sequence viewed on the videotape:

7/2/11

9:43p.m.: Patient (C1) entered bedroom.
10:07:56p.m.: MHA [Mental Health Assistant] (E1) entered the patient's bedroom from hallway, did not go all the way into room as required by hospital policy.
10:28:31p.m.: MHA (E2) entered the patient's bedroom, stayed until 10:28:52p.m. (21 seconds).
11:01:46p.m.: MHA (E2) opened patient's bedroom door; did not enter room.
11:48:50p.m.: MHA (E3) entered patient's bedroom room with flashlight; in room 9 seconds.

The above videotape recordings (for 7/2/11) document that nursing staff did not check on Patient C1 every 15 minutes as required by policy. For the checks at 10:07p.m. and 11:01p.m., the MHA did not enter the patient's room; thus adequate assessments could not have been completed.

7/3/11

12:05:49a.m. - MHA (E3) entered patient's bedroom room with flashlight; in room 10 seconds.
12:23:07a.m. - MHA (E3) entered patient's bedroom with flashlight; in room 8 seconds.
12:52:08a.m. - MHA (E3) entered patient's bedroom with flashlight; in room 5 seconds.
1:04:57a.m. - MHA (E3) entered patient's bedroom with flashlight; in room until 1:05:32. (1 minute, 35 seconds)
1:17:51a.m. MHA (E3) entered patient's bedroom with flashlight; in room 6 seconds.
1:35:39a.m. MHA (E3) entered patient's bedroom with flashlight; in room 7 seconds.
1:49:32a.m. MHA (E3) entered patient's bedroom with flashlight; in room 6 seconds.
2:05:54a.m. MHA (E3) entered patient's bedroom with flashlight; in room 6 seconds.
2:29:54a.m. MHA (E4) stood near doorway to patient's bedroom with flashlight; did not enter patient's bedroom.
2:56:40a.m. MHA (E4) entered patient's bedroom with flashlight; in room until 2:57:14. (1 minute, 34 seconds)
2:59:25a.m. (less than 3 minutes after last check) MHA (E4) went back into patient's bedroom with flashlight. Returned to nursing station at 3:00:36 and talked to RN (F1).
3:01:15a.m. MHA (E4) and RN (F1) walked to patient's bedroom and entered the room.
3:03:12a.m. Both MHA (E4) and RN (F1) came out of patient's bedroom and went to nurses' station. F1 made a phone call.
3:04:02a.m. MHA (E4) and RN (F1) returned to patient's bedroom with gloves on their hands.
3:04:50a.m. RN (F1) came out of patient's bedroom; made another phone call and obtained a B/P cuff. MHA (E4) also came out of patient's bedroom.
3:06:10a.m. MHA (E4) and RN (F1) went to get another B/P cuff.
3:06:20a.m. Nursing Supervisor arrived on the unit and went directly to patient's bedroom.
3:07:08a.m.: Nursing Supervisor ran to obtain the emergency cart.
3:08:24a.m.: Doctor on Call (DOC) arrived on unit and went directly to patient's bedroom.
3:18:50a.m.: EMT arrived on unit.
3:19a.m. EMT entered patient's bedroom.

The above videotape recordings (for 7/3/11) document that nursing staff did not do all 15 minute checks for Patient C1 as required by hospital policy. For the check conducted at 2:29a.m., the MHA did not enter the patient's room; thus the patient's condition could not have been adequately assessed. After finding the patient in distress (unresponsive), both the MHA and the RN left the patient unattended. The RN also did not immediately obtain the emergency cart for resuscitation of the patient, but waited for the nursing supervisor and DOC to arrive.

C. Policy Review

1. The facility's policy on Patient Rounds/Checks Procedure (policy number: N-P20.1) states "Patient safety is enhanced with the performance of routine patient checks by nursing staff. These checks are done every fifteen (15) minutes on each patient on South2, South3, North 2 and North 3. All patients on the Adolescent Unit are checked every five (5) minutes on the day and evening shifts and every fifteen (15) minutes on the 11-7 shift."

"PROCEDURE TO COMPLETE ROUTINE PATIENT CHECKS ON THE UNIT
1. Begin where the most patients are, e.g., in a group or day room.

2. Enter the patient room after knocking if the door is closed. You may enter a room without knocking only in an emergency. Check bathroom while in the room. If the patient is in the bathroom you must knock and let the patient know you must visually confirm their safety. Observe the location and behavior of the patient. Check under covers over head or if mound appears in bed. Ascertain the patient is breathing by observing the rise and fall of the chest and counting respirations at least 3 times and making sure patient has moved from his/her previous sleeping position. During 11-7 [night shift], patient respect and privacy must be maintained by completing rounds in a way so that minimally disturbs the patient and unit, e.g., enter room quietly, shine flash light around bed and not directly in the patient eyes. Always ascertain the patient is breathing."

For Patient C1, the staff did not consistently adhere to this policy, either in conducting round-the-clock 15 minute patient checks, or in doing all needed assessments of the patient's condition, including checks on the patient's breathing.

D. Document (Root Cause Analysis)

Review of a draft of the Root Cause Analysis for patient C1, dated 7/15/11, and provided by the facility, contained the following information:

1. For the question, "Did staff performance during the event meet expectations?", the report stated, "No, not in following check [patient rounds/checks] policy and procedure - check was late, code blue protocol and staff escort p and p. [sic]" In the box that asked if this is a root cause, "?" [question mark] was listed on the form.

2. For the question, "What Human factors may have been relevant to the outcome?" the report stated, "MHA stated he did not feel competent to start CPR by himself since pt was on his stomach. He [MHA] was scheduled to take the recert [recertification class] on 7/14/11. The RN has worked at Arbour for 17 yrs and was a physician in Nigeria. He had participated in mock code blue drills but had never been involved in code blue." In the box that asked if this is a root cause, "?" [question mark] was listed on the form.

E. Staff Interviews

1. During an interview on 7/18/11 at 2:30PM, the surveyor asked the Director of Quality Assurance/Director of Nursing about the progress note, written by the Doctor on Call (DON) the night of patient C1's death (7/3/11) which stated that the DOC give two doses of Epinephrine and initiated CPR/code blue procedures, while stating that the patient was already in rigor mortis. The Director of Quality Assurance/Director of Nursing replied, "As part of the investigation I have not been able to interview the DOC as she works weekends and has been off...She is coming in this week and I am going to be interviewing her on Thursday."

2. In an interview on 7/18/11 at 3:30PM, the Director of Quality Assurance/Director of Nursing was asked if a Root Cause Analysis for Patient (C1) had been completed. The Director of Quality Assurance/Director of Nursing replied, "I have a draft root cause that I worked on over the weekend. It is not complete and we are still working on several areas but I can show you what I have done so far."

3. During an interview on 7/18/11 at 4:05PM, the Director of Inpatient Services stated. "Patient (C1) room was chilly, I didn't touch him, his arms were by his side, lips blue, cyanotic, no odor in room, no incontinence, hands were by his side at 5a.m. 7/3/11 when I arrived."

4. In an interview on 7/18/11 at 5:20p.m., the Director of Quality Assurance/Director of Nursing was asked what immediate action had been taken to make sure the other patients are safe since the incident [with patient C1] on 7/3/11. The Director of Quality Assurance/Director of Nursing replied, "All visits are supervised for patients that have a history of substance abuse. Prior to incident any patient on South 2 could have unsupervised visits." This did not address the need for staff retraining on patient rounds/checks or CPR/code blue procedures.

5. On 7/19/11 at 11:40a.m. the Director of Quality Assurance/Director of Nursing and Director of Inpatient Services acknowledged that they [administrative staff] had identified the problems related to patient rounds/checks and emergency code procedures. As of 7/19/11, these problems were not identified in the Draft Root Cause Analysis report except for a brief notation of one missing patient check at on 7/3/11 at 2:45a.m.

6. On 7/19/11 at 1p.m., after reviewing the videotape recordings of staff rounds for patient C1, the surveyor asked the Director of Quality Assurance/Director of Nursing and Director of Inpatient Services whether they expected staff to respond more quickly to obtain the emergency care, and if at least one of the two staff members should have stayed with the patient to start CPR. Both the Director of Quality Assurance/Director of Nursing and the Director in Inpatient Services responded "yes." Although the Director of Inpatient Services acknowledged that nursing staff responses observed on the videotape were too slow, and recognized the need for Code Blue response training, the training had not been completed by the end of the survey.

Based on record review, policy review, videotape review and staff interviews, the Director of Nursing failed to assure that patient rounds/checks were conducted in a timely manner and included all required assessments, and that CPR/code blue procedures were immediately implemented for Patient C1 who was found unresponsive at by nursing staff at 3a.m. on 7/3/11, and was pronounced dead by the Physician on Call (DOC) on 7/3/11 at 3:16a.m. Review of a videotape of the patient round/checks for the night of patient C1's death revealed that staff failed to do all required patient round/checks and assessments. The nursing staff did not immediately initiate CPR [cardiopulmonary resuscitation] when they found Patient C1 unresponsive, but waited for the nursing supervisor and the Doctor on Call (DOC) to arrive. The DON failed to assure that retraining was completed for nursing staff after the death of C1 to correct the nursing deficiencies. Failure to correct nursing deficiencies results in an unsafe environment for patients, potentially resulting in additional adverse events.

A. Record Review

1. Patient (C1) was admitted on 5/12/11 for multiple symptoms of depression and the following diagnoses: "Bipolar I Disorder, Most Recent Episode Depressed, Severe without Psychotic Features, Opioid type dependence continuous, Alcohol abuse in Remission, Cannabis abuse in remission, and Cocaine abuse in remission."

2. The Discharge Summary dated 7/3/11 stated: "On 7/1/11, Mr. X (C1) expressed a better outlook on his circumstances and reported some reduction in depressive symptoms and suicidal ideation. He was in agreement about an ECT series if necessary with the understanding that a short series would avoid severe memory loss. Sadly, in the early morning hours on 7/3/11, Mr. X (C1) was found unresponsive and did not respond to resuscitation."

4. A Progress Note written by the Doctor on Call (DOC) on 7/3/11 at 3:51p.m. stated, " Code Blue was called. On my arrival. pt was lying supine. Pt was cyanotic. No pulse or resp [respirations] present. Pupils - fixed and dilated. Pt was in rigor mortis...CPR was performed. Epinephrine 1mg/IM - given twice. Resuscitation was continued for 15mts. [minutes]. 911 was called. Pt was pronounced dead at 3:16a.m."

B. Policy Review

1. The facility's policy on Patient Rounds/Checks Procedure (policy number: N-P20.1) states "Patient safety is enhanced with the performance of routine patient checks by nursing staff. These checks are done every fifteen (15) minutes on each patient on South2, South3, North 2 and North 3. All patients on the Adolescent Unit are checked every five (5) minutes on the day and evening shifts and every fifteen (15) minutes on the 11-7 shift."

"PROCEDURE TO COMPLETE ROUTINE PATIENT CHECKS ON THE UNIT

1. Begin where the most patients are, e.g., in a group or day room.

2. Enter the patient room after knocking if the door is closed. You may enter a room without knocking only in an emergency. Check bathroom while in the room. If the patient is in the bathroom you must knock and let the patient know you must visually confirm their safety. Observe the location and behavior of the patient. Check under covers over head or if mound appears in bed. Ascertain the patient is breathing by observing the rise and fall of the chest and counting respirations at least 3 times and making sure patient has moved from his/her previous sleeping position. During 11-7 [night shift], patient respect and privacy must be maintained by completing rounds in a way so that minimally disturbs the patient and unit, e.g., enter room quietly, shine flash light around bed and not directly in the patient eyes. Always ascertain the patient is breathing."

For Patient C1, the staff did not consistently adhere to this policy, either in conducting round-the-clock 15 minute patient checks, or in doing all needed assessments of the patient's condition during the patient checks, e.g., checks on the patient's breathing. (see documentations under C. Videotape Review below)

C. Videotape Review

On 7/19/11, the surveyor, accompanied by the Director of Quality Assurance/Director of Nursing and the Director for Inpatient Services viewed a videotape, that recorded the rounds checks for Patient C1 for the dates 7/2/11 (9:43p.m. to 11:48p.m.) and 7/3/11 (12:05a.m. to 3:10a.m.). The following is the sequence of events viewed on the videotape:

7/2/11

9:43p.m.: Patient (C1) entered bedroom.
10:07:56p.m.: MHA [Mental Health Assistant] (E1) entered the patient's bedroom from hallway, did not go all the way into room as required by hospital policy.
10:28:31p.m.: MHA (E2) entered the patient's bedroom, stayed until 10:28:52p.m. (21 seconds).
11:01:46p.m.: MHA (E2) opened patient's bedroom door; did not enter room.
11:48:50p.m.: MHA (E3) entered patient's bedroom room with flashlight; in room 9 seconds.

The above videotape recordings (for 7/2/11) show that nursing staff did not check on Patient C1 every 15 minutes as required by policy. For the checks at 10:07p.m. and 11:01p.m., the MHA did not enter the patient's room, so could not have thoroughly assessed the patient's condition.

7/3/11

12:05:49a.m. - MHA (E3) entered patient's bedroom room with flashlight; in room 10 seconds.
12:23:07a.m. - MHA (E3) entered patient's bedroom with flashlight; in room 8 seconds.
12:52:08a.m. - MHA (E3) entered patient's bedroom with flashlight; in room 5 seconds.
1:04:57a.m. - MHA (E3) entered patient's bedroom with flashlight; in room until 1:05:32. (1 minute, 35 seconds)
1:17:51 a.m. MHA (E3) entered patient's bedroom with flashlight; in room 6 seconds.
1:35:39a.m. MHA (E3) entered patient's bedroom with flashlight; in room 7 seconds.
1:49:32a.m. MHA (E3) entered patient's bedroom with flashlight; in room 6 seconds.
2:05:54a.m. MHA (E3) entered patient's bedroom with flashlight; in room 6 seconds.
2:29:54a.m. MHA (E4) stood near doorway to patient's bedroom with flashlight; did not enter patient's bedroom.
2:56:40a.m. MHA (E4) entered patient's bedroom with flashlight; in room until 2:57:14. (1 minute, 34 seconds)
2:59:25a.m. (less than 3 minutes after last check) MHA (E4) went back into patient's bedroom with flashlight. Returned to nursing station at 3:00:36 and talked to RN (F1).
3:01:15a.m. MHA (E4) and RN (F1) walked to patient's bedroom and entered the room.
3:03:12a.m. Both MHA (E4) and RN (F1) came out of patient's bedroom and went to nurses' station. F1 made a phone call.
3:04:02a.m. MHA (E4) and RN (F1) returned to patient's bedroom with gloves on their hands.
3:04:50a.m. RN (F1) came out of patient's bedroom; made another phone call and obtained a B/P cuff. MHA (E4) also came out of patient's bedroom.
3:06:10a.m. MHA (E4) and RN (F1) went to get another B/P cuff.
3:06:20a.m. Nursing Supervisor arrived on the unit and went directly to patient's bedroom.
3:07:08a.m.: Nursing Supervisor ran to obtain the emergency cart.
3:08:24a.m.: Doctor on Call (DOC) arrived on unit and went directly to patient's bedroom.
3:18:50a.m.: EMT arrived on unit.
3:19a.m. EMT entered patient's bedroom.

The above videotape recordings (for 7/3/11) show that nursing staff did not do all 15 minute checks for Patient C1 as required by hospital policy. Some of the checks were too brief to do a thorough assessment of the patient's condition. For the check conducted at 2:29a.m., the MHA did not enter the patient's room, so could not have thoroughly assessed the patient's condition. After finding the patient in distress (unresponsive), both the MHA and the RN left the patient unattended. The RN also did not immediately obtain the emergency cart for resuscitation of the patient, but waited for the nursing supervisor and DOC to arrive.

D. Staff Interviews

1. On 7/19/11 at 11:30a.m., the Director of Quality Assurance/Director of Nursing, and the Director of Inpatient Services Directors were asked what actions had been taken related to the deficient patient checks (noted in the videotape recordings). The Director of Inpatient Services stated, "MHA (E1) has an infraction - counseling for not following policy and procedure, and MHA (E2) has been suspended." Neither of these individual staff disciplinary actions addressed the systematic nursing failures. The Director of Inpatient Services also stated, "Supervisors were instructed to review night checks by going into patients' rooms to check breathing. This is in process but there is no documentation to date. Dummy Code Blue training is scheduled for Friday night by the night supervisor..."

2. On 7/19/11 at 11:40a.m. the Director of Quality Assurance/Director of Nursing and Director of Inpatient Services stated that they [administrative staff] had identified the problems related to bed checks [patient rounds/checks] and emergency code procedures. However, by the end of the survey, there was no evidence that these problems had been addressed in nursing staff retraining.

3. On 7/19/11 at 1p.m., after reviewing the videotape recordings of staff rounds for patient C1, the surveyor asked the Director of Quality Assurance/Director of Nursing and Director of Inpatient Services whether they expected staff to respond more quickly to obtain the emergency cart, and if at least one of the two staff members should have stayed with the patient to start CPR. Both the Director of Quality Assurance/Director of Nursing and the Director in Inpatient Services responded "yes." Although the Director of Inpatient Services acknowledged that nursing staff responses observed on the videotape were too slow, and recognized the need for Code Blue response training, the training had not been completed by the end of the survey.