HospitalInspections.org

Based on a review of documentation, the facility failed to protect the patient's right to participate in the development and implementation of his or her plan of care.

Findings were:

During a review of the treatment plan for patient #1, a master treatment plan was completed on 7-12-17. The master treatment plan revealed no nursing involvement. Although signed by the patient, the signature was not dated to indicate that the patient was present or involved during the development of the master treatment plan.

Facility policy PC-006 titled "Interdisciplinary Treatment Planning" states, in part:
"Scope:
It is the policy of the Pavilion at NWTHS that each patient admitted to the facility shall have a written, individualized treatment plan ...This team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate.
...
Procedure:
...
2. Within 3 days of admission, members of the treatment team shall further develop the Master Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status. The team will consist of the physician, the R.N. [registered nurse], the therapist/social worker, Activity Therapy staff, and representatives from other clinical disciplines, as appropriate.
...
10. The patient and/or family, if indicated, participate in the development of the plan and sign the Treatment Plan after review with a member of the treatment team. The plan will be written in age appropriate language for better understanding by the patient."

The above was confirmed in an interview with the Chief Executive Officer and other administrative staff the afternoon of 11-27-17.

Based on a review of documentation, the facility failed to protect the patient's right to care in a safe setting.

Findings were:

During the admission from 7-5-17 to 7-10-17, patient #1 was placed on suicide precautions, fall precautions and seizure precautions. The suicide precautions were discontinued on 7-7-17; the fall & seizure precautions were discontinued on 7-10-17. Upon review of her observation checklists, 4 of the 6 checklists were missing staff signatures and/or times and 1 of the 6 checklists did not specify the precaution levels for which patient #1 was to be observed.

During the admission from 7-11-17 to 7-16-17, patient #1 was placed on suicide precautions and fall precautions. The suicide precautions were discontinued on 7-14-17 and the fall precautions were discontinued on 7-16-17. Upon review of her observation checklists, 5 of the 7 checklists were missing staff signatures and/or times (required per facility policy) and 1 of the 7 checklists did not specify the precaution levels for which patient #1 was to be observed.

Facility policy PI-001 titled "Patient Observation" states, in part:
"Purpose: To ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior.
...
Charge Nurse:
a. Assigns responsibility for completion of patient observation rounds at the beginning of each shift
b. Documents assignment on the unit staff assignment sheet
c. Ensures the patient observation rounds are occurring as ordered, w4 hours per day, seven days a week.
MHT:
a. Review and update patient observation forms. Reflect changes in individual patient precaution levels, room or bed changes, new admissions and/or discharges as they occur. Fill out new patient observation forms at midnight and with any new admission woth correct precautions checked on observation sheet to match current orders, unit, date, picture and current bed location.
b. ...
c. Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient observation form.
Hand off from shift to shift:
MHT:
a. Off-going and oncoming staff will walk/monitor the unit jointly, correlating the patient location/behaviors/precautions with the Patient Observation Rounds form(s) to ensure continuity of care.
b. Both staff will initial the Patient Observation Rounds form at change of shift to indicate the completion of the handoff procedure.
Charge Nurse:
a. Will verify that rounds have been completed three times per shift and sign Observation logs a minimum of twice per shift."

The above was confirmed in an interview with the CEO and other administrative staff the afternoon of 11-27-17.

Based on facility documentation, the nursing service did not have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.

Findings were:

Review of the staffing grid/census & staffing assignments for 7-5-17 through 7-16-17 revealed staffing shortages for the nights of 7-9-17, 7-10-17, 7-11-17 and 7-12-17. On the listed nights, the unit was staffed with 1 registered nurse, 1 licensed vocational nurse and 1 mental health technician. According to the facility's staffing grid, the unit should have been staffed with 2 registered nurses and 1 mental health technician.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 11-27-17.