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Based on facility tour and staff interview, the facility failed to ensure care of all patients on the Behavioral Health units were provided in a safe setting. Specifically, the facility maintained plastic bags in several areas on the units. This failure created the potential for negative patient outcomes such as suffocation risk or strangulation by patients at risk of harm to themselves or others.

The findings were:

Tours of both adult Behavioral Health (BH) units were conducted, on 5/25/11 at approximately 11:00 a.m. The combination of the two units totaled 41 beds, however, physician coverage kept the maximum number of patients at 36. Tour on the East unit revealed plastic bags within each of the two dirty linen hampers that were located in the hallway away from direct and constant visualization of staff members.

Immediately upon the start of tour, an interview with BH Charge Nurse for the day revealed that 30 minute checks are to be done on every patient unless the patient "is new" or had a specific physician order and then 15 minute checks would be conducted instead. S/he stated that "safety checks" are also conducted and are done once a shift wherein "two people go around... through all drawers, lift mattresses, check safety things... ensure hygiene products are locked up in back..." When asked about the plastic bags present on the unit, s/he stated, "When techs are doing checks, they always observe that... We've talked about doing a cloth bag for dirty linens... When they do safety checks, they also pick up extra linens on the floor... We encourage them to change their own sheets... There is no counting of it (linens)..." The Charge Nurse stated that plastic bags were not allowed in patients' rooms.

Additional tour of the East day room revealed two small garbage cans which each contained a black small plastic bag. Two large garbage cans were also present which each contained a large clear plastic bag. When asked about the bags in the day room, the Charge Nurse stated that there was always a staff member present in the day room.

At approximately 11:25 a.m., a housekeeper was observed in one of the patient rooms on the East unit. S/he had a large rolling cart with supplies and a garbage can. Over ten large clear plastic bags as well as several large black plastic bags were draped over the garbage can. The housekeeper was in the patient room cleaning, while the garbage can was setting outside the room in the hallway. The side of the garbage can with the plastic bags was turned away from the line of sight of the housekeeper, thus leaving the potential for patients to obtain the bags. The plastic bags could not be counted by techs during routine safety checks.

A tour of the West unit, where more critically ill patients were placed, revealed additional plastic bags. Again, plastic bags were noted in each dirty linen hamper in the hallway as well as in all garbage cans in the common areas of the unit.

Although plastic bags were not present in patients' rooms and staff were present in common areas that contained plastic bags, plastic bags were easily accessible to patients on both adult units. Patients had potential to access them from unmonitored areas, which included the dirty linen hampers and the housekeeping cart. The lack of monitoring of the plastic bags posed a potential safety risk to patients, especially taking into the consideration of the acuity of patients and number of those diagnosed with suicidal or homicidal ideations.

Based on medical record review, staff interviews, and facility documents, the hospital failed to ensure that performance improvement activities tracked medical errors and adverse patient events, that the causes were analyzed, and that preventative actions and mechanisms that included feedback learning throughout the hospital were implemented. Specifically, serious care issues identified by the hospital's Risk Management Department regarding care received by sample patient #4 were not incorporated into the Quality Assessment and Program Improvement (QAPI) program. This failure resulted in lack of implementation of training and monitoring necessary to amend practices and sustain corrective actions to ensure the safety and wellbeing of patients in similar circumstances.

The findings were:

Patient #4 was admitted to the hospital, on 2/2/11, through the emergency room. S/he was diagnosed with frostbite to both hands. The medical record evidenced that the patient also had a chronic mental illness. The medical record also evidenced the patient was non-compliant with hygiene as well as dressing changes to the hands. It was also documented that the patient refused surgery for the frostbite, therefore, the plan of treatment was to let the fingers auto-amputate (fall off on their own). On 3/10/11, after approximately one month in the hospital alternating between the medical and the behavioral health units, Patient #4 was discharged to an acute treatment unit (ATU). The ATU staff identified concerns with the appearance of the frostbite wounds on the patients hands and the foul odor of the wounds. The patient was transferred via ambulance to another hospital's emergency room. Emergency room documentation showed both of the patient's hands were swollen and had open wounds with pus and drainage. The patient was documented to have been emergently scheduled for surgery. According to the operative report at the second hospital, dated 3/12/11, the patient was brought into surgery to amputate the dead and infected fingers from both hands. The facility was aware of the patient safety issues resulting in negative outcome for over two months prior to the survey. An interview with the Medical Director of the Behavioral Health Unit (BHU) was conducted, on 5/26/11 at approximately 7:15 a.m. When asked how s/he found out that the patient had received additional care after his/her hospitalization at Denver Health, s/he stated that the BHU had attempted to admit another patient to the same Acute Treatment Unit (ATU) and the ATU was reluctant to take the patient. The ATU's reluctance and its statements about the patient were discussed at the daily 11:00 a.m., "Bed Meeting" on 3/23/11 by the Director and those present at the meeting. At that time, the Director requested a review of the patient's care. The 3/27/11 "Behavioral Health Services Medical Staff Meeting" reviewed the events of this patient's care in further detail.

An interview with the facility's Director of Patient Safety, Quality, and Regulatory Compliance was conducted upon entrance to the facility, on 5/24/11 at approximately 3:00 p.m. The Director had to gather documents about the events of the patient's care, as s/he had not been the primary individual working on it. The Quality Director stated that the facility discovered the patient's issues because the ATU stated, "We're not sure we really want another patient from you ... because of her wounds." Denver Health was informed by the ATU that the patient's wounds "smelled" and that the patient was transferred to another hospital. The Behavioral Health Unit's Medical Director called the Risk Management Department and requested an evaluation. S/he stated there was an incidence review done and several opportunities were identified, which are stated below.
1. Documentation: S/he stated that the facility had a relatively new Electronic Medical Record (EMAR) system which was discovered to be very fragmented. S/he stated it was "good at inputting data but difficult to look back through and tell the story." S/he stated that, although there were many places to document, the review revealed there was no consistency of the patient's documentation and inadequacy was present.
2. Medical: S/he stated that it is not often a complicated medical patient is on the Behavioral Health Unit, however because the patient's psych needs were so extreme "it was hard (for the patient) to be on a regular unit." S/he stated the review revealed that wounds are not something the BHU often manages.
3. Non-compliance: S/he stated that the patient was "incredibly non-compliant and refused dressing changes." S/he stated that the review revealed "staff felt they were trying to protect her rights but at what point do you say the patient does not have decision making capacity?"
4. Wound care: S/he stated the patient only trusted one physician on the inpatient side to perform the dressing changes. S/he stated, "I think the plan was for wound care to set up the plan and nursing to carry out (the wound care)." S/he stated the review identified lapses in wound care.
5. Physician consults: S/he stated that the general surgery and hand surgery consult teams both saw the patient initially on acute care, but they signed off quickly and were not re-consulted. S/he stated that the physicians "don't usually continue to see" the patients and rely on nursing and wound care specialists. "We have a lot of frostbite patients and allow auto-amputation."
6. Treatment planning: S/he stated the treatment planning on the Behavioral Health Unit was identified as "not as formalized and standard" as would have been preferred for a complex patient.
7. Physician/ resident supervision: S/he stated the review revealed supervision of residents' and physicians' care was not what was expected as there was no attending physicians' signature on progress notes on several occasions.

When asked what the facility had done at that point to implement changes, the Quality Director listed several items, which are described below.
1. Documentation: S/he stated that initially when the EMAR computer vendor program went live, it was "charting by exception but last fall we began the process of changing that documentation." S/he stated the issues with the EMAR were an "ongoing process" but that "we (information technology team) meet every two weeks to look at the things that are wrong."
2. Medical & non-compliance: S/he stated the unit has looked at how to consult the right resources. S/he stated the Clinical Nurse Educator plans to use a real time training model with the staff, "although we are looking at more general Med/Surg education with the Behavioral Health RNs." S/he stated that currently the BHU RNs would call the "educator" for a problem specific answer. S/he explained that there are "educators" present throughout the hospital who specialized in different areas of expertise. "It is not in a policy at this point, but in practice that is what they are doing." S/he stated that educators work Monday through Friday, but on weekends they would have the "resource nurse."
3. Wound care: S/he stated that the facility no longer had two wound care nurses, only one. S/he stated that the Wound Care Nurse was "working on competencies for wound care education for all the units." S/he also stated "next on the list is building a wound care consult trigger in" the EMAR. S/he stated that no BHU specific education was planned as the unit sees patients to "that degree" so infrequently.
4. Physician consults: S/he stated the plan is for consults to be "included in part of the treatment planning process." The review evidenced that team members (nurses, social workers, physicians, etc) were not "talking" to each other and "now each (patient) is addressed with the entire team."
5. Treatment planning: S/he stated that the process has changed and now it is a two hour event where each physician has a half hour block and all members of the team are aware of the times when each patient will be discussed. S/he stated the patients issues are made a priority in treatment and addressed with a team decision.
6. Physician/ resident supervision: S/he stated that daily oversight of residents' notes and plans now occur. S/he stated the Medical Director mandated improved quality and content of notes.

When asked for documented evidence of the above stated changes, the Quality Director stated, at approximately 4:10 p.m., that there was "no formal plan" for education. S/he stated, "They are trying to retrieve emails that went out ..." S/he stated a meeting with the Medical Director and his/her team was conducted, but there were "no meeting minutes generated from the meeting." S/he stated, "Much of this has been done informally" including that staff training had been a "fluid at the elbow process." At that point, no documents were presented to the surveyors to evidence implemented changes despite that concerns had been identified within the Behavioral Health Unit's systems. Over the following two days, two power point presentations from the meeting, the meeting's agenda, a few emails, and some of the Medical Director's handwritten notes were provided, but no Quality Assessment and Performance Improvement plan or process existed.

The following two days, medical records and facility documents were reviewed and interviews were conducted in regards to changes made within the BHU. The following were identified as current unchanged issues:

1. Medical/wound care & non-compliance:
An interview with the BHU's Clinical Educator was conducted on 5/26/11 at approximately 10:10 a.m. S/he stated the plan is to integrate 'competency day' with acute care staff and behavioral health staff. S/he also stated that in-services are "to be rolled out in the next couple weeks." When asked about the use of educators, s/he stated, "Currently we access resources, but it is just not as formalized as it may soon be." There was an extended timeline for the completion of this education, as it was scheduled between 6/7/2011 and 9/1/2011.

An interview with a staff nurse was conducted, on 5/25/11 at approximately 11:50 a.m. When asked what the nurse would do in several situations to obtain further assistance (patient refused medications, patient would not bathe, patient had a wound), s/he ultimately stated s/he would notify the charge nurse for assistance if explaining reasons, non-threatening ways, non-forceful, or non-condescending methods were not effective. When asked about use of clinical educators throughout the facility for specific problems, s/he stated "I have not had to utilize them." When asked how staff would contact one of the clinical educator's, aside from the BHU's educator, s/he stated, "I'm assuming I can find that information on the portal."

An interview with the BHU's Charge Nurse who reviewed sample #4's medical record/case was conducted, on 5/26/11 at approximately 11:00 a.m. The Nurse stated s/he had identified several issues within the case and had presented the findings to the Medical Director at the meeting about the patient. The prominent issues noted by the nurse included inconsistency in documentation and the patient's refusal of care and medications. S/he stated, "Nurses need to speak up and know their resources." The Nurse stated that s/he had developed a power point presentation herself, in response to the Medical Director's concerns, which "identified the strengths we had ... and looked for areas we can improve on and follow-up on." However, the Nurse stated "our plan was to find an opportunity to present it to all the nurses" but that it had "not been done yet." When asked if the BHU's Clinical Educator's plans would be part of the presentation or something separate, the Nurse did not know, as s/he had been independent on this project.

Cross reference A0395 - RN Supervision of Nursing Care: for evidence of the BHU's failure to ensure nursing assessments were completed and documented.

An interview with the facility's Wound Care Nurse was conducted, on 5/26/11 at approximately 1:00 p.m. Upon researching the patient's case, s/he stated that deficiencies were noted in the wound care provided due to "compliance issues. If [s/he] liked you, [s/he'd] be fine, but if [s/he] didn't, [s/he] wouldn't let you do anything." The Wound Care Nurse stated, "[S/he] was adamantly opposed to the psych floor and said [s/he] didn't have psych issues."

The facility had a program which educated staff nurses who work on the floors about wound care so those staff may assist in each of their units, thus lessening the burden on the Wound Care Nurse. The Wound Care Nurse did not have education planned for the BHU RNs, but stated that Behavioral Health "has it on his agenda to talk to the Acute Care CNO about getting a BH nurse involved in PUPPI (the wound care education program)," however, such had not yet been done.

The Wound Care Nurse described the process for ordering wound care treatment. S/he stated that although s/he recommends treatment, the physician ultimately has to order it and that mistakes in the ordering process can and do occur, such as the physician ordering the wound care for only one day instead of ongoing. The Quality Director stated, "One of the things we are looking at is having standing order sets that [the Wound Care Nurse] can recommend which would be clearer", but such had not yet been implemented.

2. Treatment planning and physicians:
An interview with the Associate Director of the Department of Behavioral Health was conducted, on 5/25/11 at approximately 8:20 a.m. S/he stated that months prior the treatment planning process had been addressed. S/he stated they "determined a more vigorous look was needed at the medical concerns" and that staff had been instructed to look at medical issues.

Cross reference A0396 - Nursing Care Plans: for evidence of the BHU's failure to address medical issues within its multi-disciplinary treatment plans.

An interview with the BHU's Clinical Educator was conducted, on 5/26/11 at approximately 10:10 a.m. S/he stated the plan is to redo the treatment plan and add who is responsible, eliminate the limited number of goals(3), and add consults and tracking dates. However, the treatment plans, which were a paper document, had not yet been changed. In addition, current record review revealed medical issues were still not addressed within the treatment plans.

An interview with a staff nurse was conducted, on 5/25/11 at approximately 1:10 p.m. When asked if there were any recent changes on the BHU, s/he stated that treatment plans were now "more specific to the patient ... more concise" and s/he further described changes to the treatment planning meeting itself. When asked if s/he had noticed any other recent change within BHU or even with the physician documentation, s/he stated there was no different physician documentation in the charts.

In the interview with the Associate Director of the Department of Behavioral Health, on 5/25/11 at approximately 8:20 a.m., s/he explained "concrete steps" that had been generated to prevent reoccurrence of a similar issue. The steps included: medicine physicians to sign-off prior to patients' discharges to the BHU, 100% use by psychiatric physicians of the standardized progress note form, treatment planning timing and formality change, treatment planning to address medical issues, "plan around nursing management to address wounds," more aggressive documentation and discussion of patients' uncooperativeness, and a change in physician coverage on BHU. There was insufficient evidence to substantiate medicine physicians were currently signing off on patients prior to discharge to the BHU, deficient practice was cited related to the failure to address medical issues in treatment plans, staff wound education had not yet occurred, documentation changes in the EMAR were continually evolving, and staff had not been educated on any formal changes on the BHU. In addition, there was no documentation of when these activities were initiated and no formalized plan for implementation and monitoring of corrective actions.

An interview with the Chief Medical Officer was conducted in conjunction with the interview with the Associate Director of BHU. In regards to the patient, s/he stated "the outcome was the same." When asked further if the patient suffered any additional negative effects after discharge, s/he stated that s/he had not looked at the medical record from the outlying facility but that "risk" had and s/he was informed about it.

An interview with the facility's Director of Patient Safety, Quality, and Regulatory Compliance was conducted, on 5/26/11 at approximately 12:30 a.m. The Quality Director stated that s/he had not been engaged in this patient's case. S/he stated that the Medical Director of the Behavioral Health Unit contacted the Risk Management department, instead of Quality, upon learning about this patient's issues. It was evidenced that Risk and Quality were two entirely different departments. Examination of the "Department of Patient Safety and Quality" organization chart revealed that both the Quality Director and the Risk Manager report up to the Chief Medical Officer and had no direct connection or integration with each other. The Quality Director stated that Risk and "Quality Council" meet on a weekly basis to discuss cases that "straddle the Risk/QAPI world." S/he stated, "Generally QA does the follow-up," but because of the initial impression of this case, Risk took over.

When the Quality Director was asked what will change going forward so Risk Management does not take sole responsibility of patient issues that necessitate Quality oversight, s/he stated that a meeting, to take place the following day, had been set-up for over a month. The plan for the meeting was for the Risk and Quality Managers to discuss definitions of job responsibilities and duties. S/he explained that a new position titled "Patient Safety Net Analysis" had recently been created and hired to "look at each patient safety net report and occurrences." The patient safety net reports identify adverse events and issues. S/he stated the new hire position reports to the Quality Director and will refer patient issues to Risk, but that Quality will "be the keeper." However, despite these two actions (upcoming meeting with risk and newly hired position), there was no formal change in the communication and integration of the Risk Department and Quality Department should patient issues be identified outside of the "safety net reports." Should a similar issue occur and the Risk Manager be notified again instead of the Quality Director, there was no identified systemic mechanism to ensure that similar outcomes would not occur and follow through of corrective changes would not lapse. When the Quality Director was asked the state of this patient's case going forward, s/he stated that the Quality Department would ensure oversight and implementation of the case. "I guarantee there will be a plan in place on Monday," s/he stated.

In summary, although the hospital performed an investigation regarding the quality of care for sample patient #4 and identified issues that contributed to a negative outcome, interviews, medical record/document reviews, and observations evidenced that the implementation and follow-up with medical and nursing staff was not organized in a coordinated and cohesive manner, had no documented oversight to measure effectiveness of interventions and many interventions had yet to be implemented at all. Additionally, the Quality and Risk Departments had no integrated method to address patient cases that may require analysis and actions by both.

Based on the serious nature of deficiencies cited, the Condition of Nursing Services is out of compliance. The hospital failed to evidence effective, organized, patient-centered nursing services that were integrated with a hospital wide Quality Assessment and Program Improvement program within its behavioral healthcare units.

The facility failed to meet the following standards under the Condition of Nursing Services:

A 0395 RN Supervision of Nursing Care:
The facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient. Specifically, the supervising nurse failed to ensure that nursing assessments and interventions were completed and documented in the case of sample patient #4.
This failure contributed to the development and lack of identification of infection in the patient's frostbitten fingers. The failure also had the potential to effect all patients on the behavioral health units with complex medical conditions.

A 0396 Nursing Care Plan
The facility failed to ensure that nursing staff developed and kept current a nursing care plan for each patient. Specifically, the staff on the PPS Psych Unit ("Adult Behavioral Health") failed to create goals and comprehensive multi-disciplinary treatment plans which included patients' medical problems and concerns in eight (#2, 4, 6, 10, 11, 14, 18 & 19) of sixteen (#2, 4, 5, 6, 7, 10-20) PPS Psychiatric sample medical records reviewed. In addition, the multi-specialty "Inpatient Treatment and Discharge Plan" afforded space for only three goals and did not designate which care providers were responsible for such goals. These failures created the potential for a negative patient outcome including lack of oversight and treatment of medical needs.

Cross- Reference A0263 - QAPI - Condition
The hospital failed to ensure that performance improvement activities tracked medical errors and adverse patient events, that the causes were analyzed, and that preventative actions and mechanisms that included feedback learning throughout the hospital were implemented.

Based on medical record review, staff interview, policy/procedure review, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient. Specifically, the supervising nurse failed to ensure that nursing assessments and interventions were completed and documented in the case of sample Patient #4.
This failure contributed to the development and lack of identification of infection in the patient's frostbitten fingers. The failure also has the potential to effect all patients on the behavioral health unit with complex medical conditions.

The findings were:

A review of the facility's policies/procedures conducted, from 5/24/2011 through 5/26/2011, revealed the following, in pertinent parts:
"Assessment and Interdisciplinary Collaboration"
"1. Ongoing assessment and reassessment are completed by team members pertinent to their specialized area of focus.
2. Further assessment and reassessment are determined by the patient's needs and diagnosis, when indicated by practice guidelines and policies related to the patient's needs (i.e. restraints), and changes in condition or critical events. This assessment is defined further in departmental guidelines..."
"Nursing Guidelines of Care (Inpatient Behavioral Health Services)"
"III. Procedure...
C. Inpatient Behavioral Health assessments
1. An initial patient assessment is performed within the first two-hours of admission to the unit and is documented in the medical record...
5. Patient reassessments are performed twice daily and/or when patient condition warrants...
F. Documentation - an ongoing process of providing a record (on paper or electronically) of all care provided to the patient...
2. Documentation includes but is not limited to: assessment findings, intervention(s), effectiveness of intervention(s), plans of care and goal achievement and patient and family teaching."

A review of the medical record of sample patient #4 revealed:
The patient was an adult admitted to the inpatient psychiatric unit from a medical/surgical unit in the hospital on 2/19/2011. The patient had suffered frostbite to his/her fingers on both hands and had a history of schizophrenia, hypertension, and diabetes. S/he was previously placed on a Short Term Certification due to being determined to be gravely disabled and unable to make his/her own decisions which was still in place during the patient's hospitalization.

Nursing assessments were often refused by the patient and therefore not consistently completed throughout the hospital stay (2/19/11 through 3/10/11). Although, the patient had a complex medical/psychiatric situation, and lacked decision-making capabilities, there was no evidence the staff ensured appropriate monitoring and interventions. Nursing assessments were documented only 9 times on:
2/21/11 - 5:30 p.m.
2/23/11 - 10:02 p.m.
2/24/11 - 5:23 p.m.
2/27/11 - 10:25 a.m. and 4:13 p.m.
2/28/11 - 10:18 a.m. and 5:00 p.m.*
3/7/11 - 4:14 p.m.*
3/8/11 - 4:00 p.m.

*Nursing assessments documented, on 2/28/2011 at 5:00 p.m. and 3/7/2011 at 4:14 p.m., did not describe the status of the patient's skin/wounds or elaborate on abnormal findings, only that abnormal findings existed.

The patient was discharged from the facility and transferred to an outside facility (acute treatment unit) on 3/10/2011 at approximately 4:00 p.m. The patient's record had no additional nursing documentation of assessments that were completed including a discharge assessment. A nursing assessment was not documented for 48 hours prior to discharge.

The facility's Director of Patient Safety, Quality, and Regulatory Compliance was interviewed, on 5/24/2011 at approximately 3:00 p.m. S/he stated the facility had reviewed the care provided to sample patient #4 and identified areas for improvement after a review of the nursing and other documentation. S/he stated that the facility had identified that the computer documentation system had led to fragmented assessments/documentation due to having multiple areas where nursing staff were able to document. S/he stated that this seemed to be isolated to the inpatient behavioral unit's documentation as a review of the inpatient medical/surgical unit's documentation regarding this same patient (Sample records #1 and 3) did not have similar findings that would lead the facility to identify areas for improvement. S/he stated that the facility also identified determining decision-making capacity as an area the hospital could have improvements, which included striking a balance between patient rights and patient safety.

An interview with the facility's Director of Behavioral Health, on 5/26/2011 at approximately 7:45 a.m., revealed that the facility conducted a thorough review of sample patient #4's care after concerns were raised from the acute treatment unit. S/he stated that s/he had one of the unit's charge nurses review the nursing documentation. S/he stated that the patient "lacked capacity to make decisions" due to his/her psychiatric symptoms that were present consistently throughout his/her hospital stay and that the patient was on a short-term certification which meant that the hospital had an obligation to treat the patient.

An interview with the facility's inpatient behavioral health unit's charge nurse that had reviewed the nursing documentation of sample patient #4's care, on 5/26/2011 at approximately 11:05 a.m., revealed that s/he had found "under charting." S/he stated that the patient had more than the two wounds that were documented, that each finger should have been treated as a wound. S/he stated that review of the record was difficult due to multiple places that findings and interventions could be placed.

According to records from another hospital, patient #4 was diagnosed with infection and the need for emergent surgery within two days following discharge from the hospital.

Based on medical record review, staff interview, and policies and procedure review, the facility failed to ensure that nursing staff developed and kept current a nursing care plan for each patient. Specifically, the staff on the PPS Psych Unit ("Adult Behavioral Health") failed to create goals and comprehensive multi-disciplinary treatment plans which included patients' medical problems and concerns in 8 (#2, 4, 6, 10, 11, 14, 18 & 19) of 16 (#2, 4, 5, 6, 7, 10 - 20) PPS Psych sample medical records. In addition, the multi-speciality "Inpatient Treatment and Discharge Plan" afforded space for only three goals and did not designate which care providers were responsible for such goals. These failures created the potential for a negative patient outcome including lack of oversight and treatment of medical needs.

The findings were:

"Nursing Guidelines of Care (Inpatient Behavioral Health Services)," with an effective date of 4/8/11, contained a section which was titled "Patient plans of care," however, it was not stated if this section was a specific reference to the nursing plans of care or the weekly multi-disciplinary plans of care. Nonetheless, the section stated the following, in pertinent part:
"1. The patient's plan of care is identified based on assessment data and anticipated treatment(s) and is documented in the medical record.
2. The plan of care includes outcome-oriented goals related to the current health care episode and specific interventions targeted toward achievement of goals.
3. Specific interventions are evaluated for effectiveness.
4. All interventions are individualized to the patient's specific situation and address their physical, psychosocial and other problems related to the current health care episode."

The Behavioral Health's Clinical Educator was interviewed, on 5/25/11 at approximately 3:45 p.m. S/he stated that when the Division of Behavioral Health was last at the facility, they stated the nursing care plans didn't "link up with our interdisciplinary treatment plan so now the care plan goals are taken right from the treatment plan."

In a further interview with the Clinical Educator on 5/26/11 at approximately 10:10 a.m., s/he stated, in regards to multi-disciplinary treatment plans, "We realize it is a problem," and that changes were in process, but not yet implemented. S/he stated that the nurse does the admission of the patient but that the "initial treatment plan is done by the admitting doctor. The next day the interdisciplinary team looks at and tweaks the treatment plan." Therefore, the initial treatment plan could possibly be generated by a psychiatric physician only, with no input from the aspect of nursing or medicine.

A review of medical records was conducted, on 5/25/11 through 5/26/11. Review revealed the following:

Sample medical record #2 revealed an adult patient initially admitted for frostbite treatment, including wound care and dressing changes on both hands, who was on the medical unit but was then transferred to the Behavioral Health (BH) Unit from 2/11/11 due to the patient's psych problems. The patient was on BH for only two days. A consultation done by the medicine service stated, in pertinent part: "Pt is poor historian & is fixated on [his/her] frostbite; reports wants to transfer back to Medicine floor as 'they don't know what they are doing here." The patient's discharge summary stated that the patient had several other issues along with his/her long-term psychiatric diagnosis and new onset acute frost-bite, some of which included extended substance abuse, non-insulin dependent diabetes, hypertension, and limited social support. The patient's initial "INPATIENT TREATMENT AND DISCHARGE PLAN" stated three goals in the allotted spaces of which included the following: "take meds," "go to groups," and "work with staff." The "measurement" of the first goal, "take meds," was "MAR," indicating the Medication Administration Report and the "Patient Responsibilities" of the goal was "take meds as prescribed." The measurement of the second goal, "go to groups," was "progress notes" and the "Patient Responsibilities" of the goal was "attend all groups." The measurement of the third goal, "work with staff," was "prog. notes" and the "Patient Responsibilities" was "be honest to participate in treatment." A portion of the treatment plan was allotted for the patient and family to formulate goals and that portion stated "pt refused to participate." The section titled "Other Medical Conditions, Medications and Treatments" stated that the patient had frostbite, diabetes, and high blood pressure, however it did not indicate any methods wherein these conditions would be cared for or monitored. The treatment plan was only signed by the admitting physician, presumably due to the patient's short stay on the BH unit and did not address the patient's extensive medical needs as well as the patient's anxiety in regards to being on the BH unit instead of the medical floor.

Sample medical record #4 was the same patient as sample record #2, but a second admission to the BH unit from a medical/surgical unit in the hospital, on 2/19/2011 and discharged on 3/10/11. The patient had suffered frostbite to fingers on both hands and had a history of psychiatric problems, hypertension, and diabetes. The record contained documents that were titled "Behavioral Health Goals" that served as the patient's care plan, but no master treatment plan was evidenced in the medical record. The goals were general; on 2/21/2011 at approximately 1:49 a.m. the goals were "safety, improved psychosis, and med self care" which were to be measured by "daily assessment." There was no indication of the interventions that would be used to attain the goals, or what measurable outcome was expected with the goals to identify when the patient goals would be met. Documentation on 2/22/2011 at approximately 10:35 p.m. stated that the three goals were ongoing and that the patient's progress included: "safe on unit, unclear, and taking meds." The evaluation of the patient's progress towards the defined goals was not done regularly and, when the patient did not meet goals according to the documentation, there was no revision to the plan in the documentation, nor was there documentation of the interventions attempted to attain the defined goals. The plan did not address the patient's medical conditions that were documented elsewhere in the patient's chart, which included frequent required dressing changes to both hands, pain resulting from the frostbite, diabetes, and hypertension.

Sample medical record #6 was an adult patient who was admitted to the hospital for five total days due to "worsening depressive symptoms, suicidal ideation and a plan to cut... wrists." The record did not contain a nursing care plan or an interdisciplinary care plan. In an interview with the hospital's Behavioral Health Nurse Educator on 5/26/2011 at approximately 10:40 a.m., s/he stated that, after inspecting sample patient #6's record, "I don't see it [a care plan for the patient]."

Sample medical record #10 was an adult patient admitted to the BH unit on 3/24/11 and currently still on the unit upon record review. The patient's "PSYCHIATRIC HISTORY AND PHYSICAL" stated the patient had a history of psych problems as well as polysubstance abuse, hypertension, hypercholesterolemia, chronic hip pain, and gastro-esophageal reflux. In addition, it stated, "history of cardiac problems, followed for chronic pain..." The "PATIENT TREATMENT AND DISCHARGE PLAN" for the following dates were reviewed: 3/28/11, 4/4/11, 4/11/11, 4/18/11, 5/2/11, 5/6/11, 5/13/11 and 5/19/11. The patient's three initial goals from the 3/28/11 plan were "increased organized thought process," "increased orientation," and "identify plans for follow-up." The patient's three goals from the most recent plan, dated 5/19/11, were "decreased suicidality" and "decrease psychosis/affective/ability." None of the multi-disciplinary treatment plans, which were signed by physicians, nurses, social workers, clinical nurse specialists, etc, addressed any medical issues beyond psychiatric needs. Although the "Other Medical Condition, Medications and Treatments" section consistently stated the patient's medical issues, the section did not at any time indicate any methods wherein these conditions would be cared for or monitored, including the patient's consistently documented chronic right hip pain.

Sample medical record #11 was an adult patient admitted to the BH unit, on 5/22/11 and upon record review was currently a patient on the unit. The patient's "PSYCHIATRIC HISTORY AND PHYSICAL" stated that information was obtained using a phone interpreter, due to the patient's language barrier. The Attending physician's note stated, in pertinent part, "Pt refused an interpreter but [able] to communicate in simple English..." Additional documentation stated, "...check screening labs... has had elevated BP in PES. If continues to be up, will need medicine consult..." The patient's only 'INPATIENT TREATMENT AND DISCHARGE PLAN," signed by all disciplines, stated that the patient had no other medical conditions, medications, or treatments and no "Patient-Specific Consideration." The patients only goals included "decrease psychosis" and "improve sleep." The treatment plan was not comprehensive of all the patient's needs.

Sample medial record #14 was an adult patient admitted to the BH unit, on 5/4/11 and upon record review was currently a patient on the unit. The patient was being treated for psych problems but also had a history of diabetes and was non-English speaking with cultural barriers noted. The medical record revealed that the patient's language barrier was not documented on the initial treatment plan done upon admission, but was implemented on the second treatment plan done one week later.

Sample medical record #18 was an adult patient admitted to the BH unit, on 5/15/11 and upon record review was currently a patient on the unit. The patient's current medical history included a psych condition with an acute exacerbation, a urinary tract infection, pregnancy, recent exposure to a contagious disease, topical skin issues, as well as past drug abuse. In addition, the patient had many social needs, including the need to get to a foreign country to be with family and grief due to relationship issues. The patient had two "INPATIENT TREATMENT AND DISCHARGE PLAN," signed by most disciplines. The first, dated 5/16/11, stated one goal: "Reduction of depressive symptoms," which was to be measured by "Pt report, observation of pt," and the patient's responsibilities of such goal, that was legible, was: "Pt to attend groups and remain med compliant..." The treatment plan did state the patient was pregnant and had a urinary tract infection. The second "INPATIENT TREATMENT AND DISCHARGE PLAN" stated that the patient had two goals: "Reduce depression and SI" and "Maintain safety on unit." The "Other Medical Conditions, Medications and Treatments" section stated the patient's pregnancy again, that her urinary tract infection was "resolved" and that the patient had a recent exposure to a disease and few details related to that. However, the section did not at any time indicate any methods wherein these conditions would be cared for or monitored nor did the plan address the patient's skin issues. Additionally, the "Discharge Planning" section was the only area where the patient's social needs were addressed.

Sample medical record #19 was an adult patient admitted to the BH unit, on 5/11/11 and upon record review was currently a patient on the unit. The patient's current medical history included a psychiatric diagnosis as well as some medical complaints of ear pain, leg pain, and noted hypoxia. The patient's record contained three "INPATIENT TREATMENT AND DISCHARGE PLAN" dated 5/11/11, 5/19/11 and 5/26/11, signed by all disciplines. The first, dated 5/11, stated the following three goals: "stop hearing voices," "feel safe," and "correct my medication regimen." The measurement for these three goals included "report of sx (symptoms) to staff," "reporting unsafe thoughts, staff obs. (observation) of beh (behavior)," and "tolerating meds." The second multi-disciplinary plan contained two goals: "stop AH (auditory hallucinations)/ paranoia" and "correct meds." The third and final plan contained two goals: "reduce paranoia/ AH" and "complete med titration." Each of the "Other Medical Conditions, Medications and Treatments" stated the patient's B12 deficiency and/or hypothyroidism. However, the patient's other medical issues (ear pain, leg pain, hypoxia) were not addressed on any of the treatment plans and the medical issues that were referenced did not indicate any methods wherein these conditions would be cared for or monitored.


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