HospitalInspections.org

Based on review of the facility's policy and procedure, medical records (MR) and interview with staff it was determined the facility failed to ensure a initial nursing assessment (to include all psychiatric assessments) was completed on each patient within 24 hours of admission. This affected 1 of 6 MRs reviewed including Patient Identifier (PI) # 2 and had the potential to affect all patients admitted to the facility.

Findings include:

Policy: Nursing Assessment
Last Revised: 09/2019

Policy:

Each patient admitted to Unity will have a nursing assessment completed the first day of treatment.

Procedure:

A Registered Nurse (RN) will complete the Nursing Assessment on the first day of treatment:
...7. The assessment is to be started upon admission and completed within the first 24 hours.
8. The RN should date, time and sign the time the patient was admitted and when the assessment began. The RN should also date, time and sign once the assessment has been completed.

1. PI # 2 was admitted on 10/14/19 with diagnoses including Schizophrenia Unspecified.

Review of the Initial Nursing Assessment (INA) dated 10/14/19 revealed the admission time was 4:50 PM. The INA was signed by Employee Identifier (EI) # 7, RN, on 10/14/19 at 6:30 PM. The following areas of the INA were incomplete:

a. Patient's or family's perception of the patient's: Strengths, Needs, Abilities, Preferences and Goals or Expectations of Hospitalization

b. What other psychiatric meds have you been prescribed?

c. Recent Stressors/Changes

d. Personal Safety Plan

e. Psychological Trauma History

f. Pain/Discomfort

g. Mobility

h. Family History

i. Patient/Family Education Needs

j. Assessment Summary

Review of the MR revealed EI # 7 documented a nursing assessment (shift assessment) for PI # 2 at 8:00 AM on 10/15/19, and a narrative note at 2:00 PM.

EI # 7 failed to complete the Initial Nursing Assessment for PI # 2 within 24 hours of admission (10/14/19 at 4:50 PM).

An interview conducted on 10/17/19 at 11:50 AM with Employee Identifier # 6, RN Risk Manager, confirmed the Initial Nursing Assessment was incomplete.

Based on review of medical records (MR), policies and procedures, personnel files, job descriptions, Master Employee List, and interview with staff, it was determined the facility failed to ensure:

a) The Psychosocial Assessments were completed by the case manager or social worker.

b) The LMSW (Licensed Master Social Worker) employee who cosigned the Initial Psychosocial Assessments had completed orientation and was qualified to do so.

c) The Psychotherapy Progress Notes were completed by qualified personnel.

d) Staff authenticated entries in the MR according to policy.

This affected 3 of 6 records reviewed, and did affect Patient Identifier (PI) # 3, PI # 4, PI # 5, and had the potential to affect all patients admitted to the facility.

Findings include:

Policy: Psychosocial Assessment
Last Revised: 10/2019

Policy: Each patient admitted to Unity Psychiatric Care will have a Psychosocial Assessment completed within 72 hours of admission.

Procedure: The psychosocial assessment is completed by the case manager or social worker. They will gather information to clarify the reciprocal impact of the patient's symptoms and environment...

Policy: Multidisciplinary Progress Notes
Last Approved: 10/2019

Policy: Progress notes will be maintained on all patients.

Procedure:

3. The progress note must be recorded by the physician, nurse, social worker and when appropriate others significantly involved in active treatment modalities.

Title: Job Description for Director of Social Services
Date Revised: 3-2015

Policy: The Director of Social Services provides effective clinical services to include group, individual and family therapy as ordered by the physician... Develops and implements individualized treatment plans utilizing therapeutically recognized interventions...

Procedure:

A. Qualifications:
1. Education- Master's degree in social work...
2. Experience- Two or more years of clinical experience with severe and persistent mental illness and/or geriatrics preferred. Supervisory experience preferred.
3. Certification- L.C.S.W. (Licensed Clinical Social Worker) or other clinical license or certification preferred.
...5. Skills
...b. Comprehensive knowledge in completing and conducting psychosocial assessments, social history, and assessing high social risk cases.
c. Comprehensive knowledge in counseling for patient, family, and caregivers regarding mental health.
d. Comprehensive knowledge of treatment plans, goals, and modalities that are patient specific.
...f. Knowledge of mental health treatment issues, including DSM-V (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) diagnostic criteria and psychotropic medications.
...i. Comprehensive knowledge in hospital procedures, federal and state laws, accreditation requirements of psychiatric hospitals.

B. Job Responsibilities
1. Works... to assure provision of appropriate social services to patients admitted to the hospital.
2. Interview patient, families or significant others to complete a thorough psychosocial assessment and collect data pertinent to treatment and discharge planning within 72 hours of admission to BHC-H (Behavioral Healthcare Center- Huntsville) [Former name of facility].

Title: Job Description for Activity Therapist
Date Revised: 3-2016

Policy: The Activity Therapist will implement and develop therapeutic activities for all patients. Monitors patient's progress during treatment and is an active member of the treatment team. Performs activity therapy assessments on all patients and other duties as assigned.

...B. Job Responsibilities
1. Evaluate all patients for therapeutic activities and implements plans as appropriate.
2. Performs Therapeutic Assessments an all patients within the appropriate time frame....

Policy: Medical Record Standards
Date Revised: 9/2019

Policy:The Medical Record is... maintained for the benefit of the patient, physician, and the hospital.

Procedure:

...2. Authentication- ...shows authorship and assigns responsibility for an act, condition, opinion, or diagnosis. All entries in the medical record must be authenticated...

3...b. Handwritten Documentation entries will be timed, dated, and signed on each entry.

1. PI # 3 was admitted to the hospital on 10/8/19 with diagnoses including Major Neurocognitive Impairment with Mood and Behavioral Disturbance, and Schizophrenia.

Review of the MR revealed the Psychosocial Assessment was performed on 10/9/19 by Employee Identifier (EI) # 4, Activities Therapist. The Psychosocial Assessment was also signed by EI # 5, LMSW, Director of Social Services, who was hired on 10/7/19. There was no date or time documented when EI # 5 signed the Psychosocial Assessment, as directed by the hospital policy.

Further review of the MR revealed a Weekly Psychotherapy Progress Note, dated 10/16/19, performed by EI # 4. The Note included Goals, Interventions, Progress, and Discharge Plan. The Progress Note was not signed by a social worker.

During an interview on 10/16/19 at 4:50 PM with EI # 3, Director of Nursing (DON), it was confirmed the Activities Therapist performed the Psychosocial Assessment and Weekly Psychotherapy Progress Note.

2. PI # 4 was admitted on 9/17/19 with diagnoses including Major Neurocognitive Disorder with Mood Disturbances.

Review of the MR revealed 2 weekly Psychotherapy Progress Notes, dated 10/8/19 and 10/16/19, completed by EI # 4. The Progress Notes were not signed by a social worker.

During an interview on 10/16/19 at 4:50 PM with EI # 3, it was confirmed the Activities Therapist performed the Weekly Psychotherapy Progress Notes.

3. PI # 5 was admitted to the hospital on 10/4/19 with diagnoses including Major Depressive Disorder, Recurrent Severe with Psychoactive Features.

Review of the MR revealed the Psychosocial Assessment was performed on 10/7/19 by EI # 4. The Psychosocial Assessment was also signed by EI # 5, LMSW, Director of Social Services, who was hired on 10/7/19. There was no date or time documented when EI # 5 signed the Psychosocial Assessment, as directed per the hospital policy.

Review of the Weekly Psychotherapy Progress Note dated 10/11/19, revealed EI # 4 completed the assessment, goals, interventions, progress notes, and discharge plan. The Progress Note was not signed by a social worker.

During an interview on 10/16/19 at 4:50 PM with EI # 3, the above findings were confirmed.

Review of EI # 5's personnel file revealed a signed Job Description for Director of Social Services. There was no date of when EI # 5 signed the form. Review of the Master Employee List, dated 10/15/19, revealed a hire date of 10/7/19. There was no documentation EI # 5 had two or more years of clinical experience with patients or had knowledge of mental health treatment issues, treatment plans, and knowledge of psychotropic medications, as listed in the Skills section of the Job Description.

During an interview on 10/17/19 at 10:20 AM with EI # 2, the surveyor asked how the hospital determined the new Director of Social Services was competent to perform and oversee care to psychiatric patients. EI # 2 stated EI # 6, MSW will continue employment until the new director is trained and deemed competent. EI # 6 was absent during the survey.

EI # 2 further confirmed EI # 5 had not completed orientation and training, but was already providing oversight to other employees.

Review of EI # 4's personnel file revealed a signed Job Description and qualifications for the position of Activities Therapist. There was no documentation of a degree in Social Work.

The facility failed to ensure a trained and qualified social worker was available for patient care.