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Based on medical record review, staff interview and review of the policies and procedures, it was determined the facility failed to ensure the patient remained free from all forms of abuse or harassment. The facility failed to ensure the patient remained free from neglect (as a form of abuse) when documented pain 10/10 was not addressed. This failure resulted in a negative patient outcome.

Findings were:

On 1/27/2010 the facility policy entitled, "Dental Services," Policy #8.20 read, pertinent in part, "In the event dental coverage is unavailable immediately, unit staff will continue to administer first aid and secure medical consultation for evaluation and pain control, if necessary."

On 1/27/2010, the medical record of Sample Patient #5 was reviewed. The medical record contained a nursing care plan, dated 09/23/10, with the pain assessment indicating patient denied pain.

On 11/22/10, the nursing note stated, "Pt refused dental appt. to evaluate pain level 10 out of 10-front lower teeth. Will attempt to reschedule." No updated nursing care plan was completed after the patient's complaint of pain, nor any documentation that the medical doctor, the psychiatrist, or the dentist was notified.

On 11/28/10, the psychiatrist progress notes failed to address the patient's pain. The physician's notes and plan stated, in pertinent part, "increase Risperodal ...to stable mood, decrease paranoia, improved behavior, consider ECT (electroconvulsive therapy)." There was no documentation referring to the patient's tooth pain.

On 12/02/10, there was still no order for pain medications or documentation addressing the patient's pain. A nursing note stated "patient's facial color more chalky looking than usual and am familiar with patient for past many years." The nursing documentation failed to address the change in condition from previous shifts, and there was no documentation in the medical record that this new finding was communicated to the physician, psychiatrist or dentist, or that a physical assessment of the patient was conducted.

On 12/05/10, the medical record of Sample Patient #5 documented the patient pulled out his/her four lower front teeth. The facility neglected to provide care to the patient and to address her/his pain, neglected to notify /communicate the patient's pain and change of condition to the physician, psychiatrist or dentist, resulting in the patient removing his/her four lower front teeth.

On 01/27/2011, at approximately 1:30 p.m., interview with Director of Nursing confirmed that the chart failed to contain documentation addressing patient pain findings, from 11/22/10 to 12/05/2010, when the patient pulled out his/her four lower front teeth and failed to document that pain was discussed with a physician, psychiatrist or dentist, or that any pain medication or alternatives were ordered, resulting in negative patient outcome.

Based on a review of medical records, staff/physician interviews and review of facility policies/procedures/medical staff rules and regulations, the facility failed to ensure that a history and physical was completed or updated appropriately for sample patient #11.

The findings were:

1. Review, on 1/26/11, of the medical record of Sample Patient #11 revealed that the patient was an adolescent patient who had been discharged and then re-admitted in less than 30 days. Review of the history and physical (H & P) in the chart revealed that it was a xeroxed copy of the (H & P) competed by another physician during the previous hospitalization. A different physician had reviewed the copy of the original (H & P) and had added written notes in the body and margins of the document, had crossed out dates and sentences in the content, signature of the original physician and then signed the 7-page document. The document was left in the record as the reviewed/updated (H & P).

2. On 1/26/11 at approximately 1 p.m., the chief psychiatrist for quality assurance/standards compliance was interviewed and presented with the "revised" history and physical for Sample Patient #11. S/he was asked if the revision of the history and physical was acceptable and met medical staff practice standards and written requirements. S/he stated: "Just barely." When asked about specific standards regarding appropriate revision of a history and physical if the patient was readmitted soon after discharge, the chief psychiatrist referred the surveyor to the following section III. A. 2. of the policy and procedure "Health Assessments."

3. Review, on 1/27/11, of the facility policy/procedure "Health Assessments," revealed the following, in pertinent parts:
"I. DEFINITION/PURPOSE:
It is the policy of (the facility) to complete a full and timely health assessment on every patient admitted to the hospital.
The purpose of this policy is to describe when and how health assessments are completed, what items are included, and documentation requirements.
II. ACCOUNTABILITY:
Individuals responsible for implementing this policy include the admitting physicians, on-call physicians, midlevel providers (PA, NP), division psychiatrists and nursing personnel.
III. PROCEDURE:
A. Initial Health Assessments
...2. For medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any changes in the patient's condition is completed within 24 hours of admission, but prior to surgery or a procedure requiring anesthesia services..."

4. On 1/27/11 at approximately 8 a.m., the superintendent of the facility (a psychiatrist) and the chief of the medical staff (a medical physician), were interviewed and presented with the "revised" history and physical for Sample Patient #11. They were asked if the revision of the history and physical were acceptable and met medical staff practice standards and written requirements. The superintendent stated "the only thing right about it is it is timely." Both physicians stated that it was unacceptable and that the physician involved would be told that the revision was unacceptable. They clarified that the revision being reviewed did not represent common practice by that or other physicians in the facility. At the end of the interview, the chief nursing officer, an assistant superintendent and a consultant/assistant superintendent also reviewed the revision in question and all reiterated that the example was not acceptable. They further stated that because the revision was done by a different physician and because the initial history and physical was so extensively altered, they believed it should have been re-dictated using the alteration and notes as a draft for dictation of a completely updated history and physical.

Based on staff interview, review of medical records and the facility's policies and procedures, the facility failed to implement a nursing care plan and ongoing assessment for two (#5 and #28) of 30 medical records reviewed. This failure created the potential for negative patient outcome.

The findings were:

1. The facility's policy and procedure entitled, "Plan of Care," effective date of 12/30/10 reads, in pertinent part: "It is the policy of CMHIP that patients admitted to CMHIP have a written, individualized Plan of Care. This plan is based on an interdisciplinary assessment as well as the ongoing review of the patient's needs."

The medical record of patient #28 was reviewed on 1/26/11. The patient was admitted to the facility, on 11/9/10, for a risk assessment and discharged on 11/16/10. The patient was also diagnosed with a medical issue regarding an infection to the right great toe. During the patient's seven day admission there was no plan of care initiated.

An interview was conducted with the Director of Nursing (DON), on 1/27/11 at approximately 7:40 a.m. The DON stated that the patient had been admitted by the court for a risk assessment. S/he stated that an interim plan of care should have been initiated, especially for the medical issue regarding the infected toe.


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2. Sample medical record #5

On 1/27/2011, the medical record of Sample Patient #5 was reviewed. On 09/23/2010, the last updated nursing care plan in medical record, the patient's pain assessment indicated the patient denied pain.

On 11/22/10, the nursing note stated, "Pt refused dental appointment to evaluate pain level 10 out of 10-front lower teeth. Will attempt to reschedule." No updated nursing care plan was completed identifying the patient's pain nor was there any documentation that the patient's pain had been addressed with any physician or dentist.

The facility policy titled "Dental Services" #8.20, revealed pertinent in part, "In the event dental coverage is unavailable immediately, unit staff will continue to administer first aid and secure medical consultation for evaluation and pain control, if necessary." The medical record of Sample Patient #5 revealed no evidence of any consultation for pain evaluation or treatment for pain.

On 11/28/10, the psychiatric physician progress notes failed to address pain, and the physician's plan states, in pertinent part, "increase Risperodal ...to stable mood, decrease paranoia, improved behavior, consider ECT (electroconvulsive therapy)." There was no documented order for pain medications or notes addressing the patient's pain.

On 12/02/10, the nursing note stated "patient's facial color more chalky looking than usual and am familiar with patient for past many years." The nursing documentation failed to address the change in condition from previous shifts, and there was no documentation in the medical record that this new finding was communicated to the physician, psychiatrist or dentist, or that the patient's continued pain was being addressed.

On 12/05/10, the medical record of Sample Patient #5, documented the patient pulled out his/her four front teeth.

On 01/27/2011, at approximately 1:30 p.m., an interview with Director of Nursing confirmed that the chart failed to contain documentation addressing the patient's pain issues, from 11/22/10 to 12/05/2010, when the patient pulled out his/her four front teeth. The Director of Nursing also confirmed that nursing care plans are required, per policy, to be updated once annually unless there is a "new finding" in daily nursing assessment. No care plan update was documented despite changes in the patient's condition. There was no documentation the patient's change in condition or pain was discussed with a physician, psychiatrist or dentist, or that any pain medication or alternatives were ordered. The facility failed to address and document, evaluate, and communicate the patient's need for pain medication resulting in the patient "pulling out" her front teeth.