HospitalInspections.org

Based on interview, record review, and policy review the facility failed to develop/maintain a comprehensive and interdisciplinary treatment plan for one discharged patient (#5) of four care plans reviewed on the behavioral health unit (BHU). This failure could potentially lead to improper provision of care for all psychiatric patients. The BHU census was one. The facility census was 21.

Findings included:

1. Record review of the facility's policy titled, "Interdisciplinary Treatment Team" dated 10/30/13, showed that:
- An initial treatment plan was developed within 24 hours of admission and guided treatment until the interdisciplinary treatment (IDT) plan was developed.
- Safety concerns and problems requiring immediate attention were communicated to the physician and incorporated into the initial treatment plan.
- Nursing generated a problem list, treatment team members added problems, and a consolidated list was presented within three days of admission during the IDT meeting.
- Each attending IDT member was responsible for documenting relevant problems, goals and objectives, necessary treatment modalities (interventions), expected outcomes and target dates in the IDT plan.
- The IDT plan was reviewed at least weekly by the IDT, or more often as necessary.
- The IDT plan was coordinated by the BHU Program Director.

Record review of the facility's policy titled, "Violent/Homicidal Patient Behavior Management Protocol" dated 08/09, showed that violence was the acting out of emotions of fear or anger to achieve desired goals. Homicidal behavior was defined as violence with the intent to kill directed at another person. The psychosocial assessment was identified as the initial assessment for the Behavioral Health Unit (BHU).

2. Record review of Patient #5's Psychiatric Evaluation dated 12/12/13 showed the patient was admitted to the facility on 12/11/13 with a diagnosis of chronic intermittent explosive disorder (characterized by several episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property). The physician identified intermittent explosive disorder as one of the patient's problems and the patient was told that he needed to help control his behavior to prevent recurrent hospitalizations.

3. Record review of Patient #5's psychosocial assessment dated 12/12/13 showed the patient stated that he was served divorced papers and a restraining order, he snapped, and threatened to kill his wife.

4. Record review of Patient #5's admitting nurses' note dated 12/11/13, review of the nursing care plan dated 12/11/13 and the initial treatment plan dated 12/14/13, showed no problems, goals, objectives, or interventions for violent/homicidal behavior towards others.

5. Record review of Patient #5's nurses' notes dated 12/14/13, at 12:18 AM, showed that on 12/13/13 at 8:00 PM:
-The patient was angry and upset and stated that it was the anniversary of his aunt's death, who was murdered by his dad.
-The patient stated that he should have killed his father while he had the chance, and as a child his father raped him on many occasions.
- He was observed in his room punching the wall.

6. Record review of Patient #5's IDT plan dated 12/14/13 through discharge on 12/16/13, showed no problems, goals, objectives or interventions for violent/homicidal behavior. The facility failed to evaluate the behaviors and institute interventions in the patient's treatment plan to address the patient's violent/homicidal thoughts and behaviors.

7. Record review of Patient #5's Discharge Summary dated 12/16/13, showed the patient was readmitted to the facility after being discharged for a couple of days. He reported that he went to court following the previous discharge and received divorce papers and an ex parte order (temporary orders such as a restraining order or temporary custody). The patient was very angry and upset and noted that he cannot control his anger or aggression. The patient's mood was stabilized and he was discharged on 12/16/13.

8. During an interview and concurrent record review on 12/17/13 at 10:15 AM, Staff E, Registered Nurse (RN), stated that Patient #5 was admitted with reports of making homicidal threats to his wife and his brother. When Staff E reviewed the IDT plan, he stated that he was unsure why the document failed to show problems, goals, objectives and interventions for the patient's violent/homicidal behavior.

9. During an interview and concurrent record review on 12/17/13 at 3:50 PM, Staff U, Licensed Clinical Social Worker (LCSW) and BHU Program Director, stated that the social worker should have incorporated the violent/homicidal behavior from Patient #5's psychosocial assessment into his IDT plan, and she had not. He also stated he regularly completed quality monitoring for treatment plan compliance. The monitoring form titled, "Data Retrieval Form" dated 12/12/13, failed to identify the scope of the patient's problems and that the IDT plan had not addressed his violent/homicidal behavior.





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Based on observation, interview, and policy review the facility failed to:
-Follow their policy for hand hygiene (use hand sanitizer or wash with soap and water) for three patients (#9, #10 and #14) of three patients observed and follow their policy for hand hygiene with glove use for two patients (#2, and #13) of three patients observed.
-Ensure staff held the urine collection bag at a low level when changing patient position in bed for one patient (#2) of one patient observed with a urinary catheter (a tube inserted into the patient's bladder to drain urine) drainage bag.
- Ensure a clean surface, for patient linen, for one patient (#11) of one patient observed for a linen change. The facility census was 21.

Findings included:

1. Record review of the facility's policy (Structure Standards) titled, "Standard Precautions for Employee Protection," dated 11/13, showed direction for facility staff to perform hand hygiene under the following conditions:
- Upon entering a patient's room.
- When leaving a patient's room.
- Before donning gloves.
- After removing gloves.
- Immediately after soiling with blood or body fluids.
- If hands will be moving from a contaminated-body site to a clean-body site during patient care.

2. Observation on 12/17/13 at 10:15 AM showed Staff O, Patient Care Technician (PCT):
- Entered Patient #9's room and failed to perform hand hygiene. Staff O remained in Patient #9's room for a couple of minutes. Staff O left Patient #9's room and failed to perform hand hygiene.

- Staff O entered Patient #10's room and failed to perform hand hygiene. Staff O remained in Patient #10's room for a couple of minutes. Staff O left Patient #10's room and failed to perform hand hygiene.

- Staff O entered Patient #14's room and failed to perform hand hygiene. Staff O remained in Patient #14's room for a couple of minutes. Staff O left Patient #14's room and failed to perform hand hygiene.

- Staff O returned to nurses station and conversed with nursing staff without performing hand hygiene.

3. During an interview on 12/17/13 at approximately 10:40 AM Staff O, stated that she just wanted to talk to the patients and that she guessed that she had better watch for hand hygiene, that she didn't remember doing hand hygiene.

4. Observation on 12/17/13 at 10:45 AM showed Staff P, Registered Nurse (RN), bathing Patient #2. Staff P wiped stool from Patient #2's buttocks. Staff P failed to perform hand hygiene after glove removal and before putting on another pair of gloves. Staff P changed her gloves three times during the bathing procedure and failed to perform hand hygiene with all three of the glove changes.

5. During an interview on 12/17/13 following the bathing procedure Staff P stated that she should have performed hand hygiene.

6. Observation on 12/17/13 at 1:50 PM, showed Staff T, Lab technician, assisting with a blood draw on Patient #13. Staff T left Patient #13's room with his gloves on, removed his gloves and proceeded to leave the Intensive Care Unit (ICU) without hand hygiene.

7. During an interview on 12/17/13 at 2:00 PM, Staff T stated that he knew the policy was to perform hand hygiene after using gloves to draw blood. He stated that he was just not in the habit yet.

8. Record review of the facility's policy titled, "Urinary Catheters" dated 2010 showed direction for the facility staff to place the urinary drainage bag below the level of the bladder (body structure that collects and holds urine). The rationale is that correct positioning of the drainage bag prevents urine reflux (return) into the bladder and ensures proper drainage and minimizes the risk of infection.

9. Observation on 12/17/13 at 9:45 AM showed Staff Q, RN, [who was assisting Staff P, during bathing], holding the urine bag for Patient #2 approximately a foot above the patient's bladder. Urine in the drainage tubing was observed returning to the patient's bladder.

10. During an interview on 12/17/13 at approximately 11:00 AM, Staff Q stated that she did not realize that she had held the bag too high. Staff Q stated that if the urine runs back into the patient's bladder, it places the patient at risk for an infection. Staff P confirmed during the interview that the bag was "held too high".

11. Record review of the facility's policy titled, "Bed Making" dated 2010 showed direction for the facility staff to consider safety and infection control practices when making beds and that it is important to keep linen clean. Linen should be assembled and placed on a clean linen bag on the patient's bedside table.

12. Observation on 12/17/13 at 9:00 AM showed Staff N, RN, placed clean linen on the lid of a soiled trash container.

13. During an interview on 12/17/13 at approximately 9:05 AM, Staff N stated that placing the linen on the trash container lid was not appropriate.














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