HospitalInspections.org

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Based on interview, document review, and review of quality documents, the hospital failed to develop and implement performance improvement activities and action plans that support hospital quality indicators related to patient safety and quality of care.

Failure to develop projects and action plans based on results of data collection aimed at improving patient outcomes places patients at risk from harm due to substandard care.

Findings included:

1. Document review of the hospital's Quality Assurance Performance Improvement (QAPI) plan titled, "Process Improvement Plan," dated 01/21, showed that the program supports the hospital by evaluation of program effectiveness through performance measures, action plans for poor performance, development of performance targets and ongoing quality improvement projects.

2. On 02/10/22 at 10:00 AM, an interview with the Director of Risk Management showed that there was not yet a 2022 Quality Assurance Performance Improvement (QAPI) plan detailing quality indicators, because the Director of Quality and Performance Improvement was out on leave. The Director of Risk Management stated that she was also unable to discuss 2022 performance improvement projects as she did not have access to the Director of Quality's computer drive.

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Based on interview, record review, and review of policies and procedures, the hospital failed to ensure that the medical records, including the Master Treatment Plans (MTPs) contained documentation recording the patient's progress from all disciplines involved in providing active treatment modalities, as demonstrated by record review for 8 of 9 active sample patients (Patient #1506, #1507, #1508, #1510, #1511, #1512, #1513, and #1514).

Failure to ensure that staff who provided active treatment modalities documented the patient's progress towards treatment goals in the medical record, including the MTP, may result in a lack of communication between the multidisciplinary team providing patient care, create barriers to adequate care, and ultimately delay discharge from the hospital.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Interdisciplinary Treatment Plan," policy number PC.ITP.101, last revised 09/21, showed the following:

a. The purpose of the treatment planning is to provide a complete, individualized, plan of care based on an integrated assessment of the patient's specific needs and problems, and prioritization of those needs/problems.

b. The patient's progress and current status in meeting the long-term and short-term goals and objectives of his/her treatment plan shall be regularly recorded in the patient's medical record.

2. Document review of the hospital's policy and procedure titled, "Plan for Provision of Patient Care," policy number L.PPPC.100, last revised 10/21, showed the following:

a. The hospital has an interdisciplinary approach to treatment planning. Those involved in the treatment planning process, include the patient's physician, nursing, therapists, activity therapists, and mental health technicians. Dietitians and pharmacists are included as indicated. The team is responsible for development of the individual treatment plan and review and evaluation for ongoing treatment.

b. Patient progress in meeting the treatment plan goals is documented in the progress notes in the patient's medical record.

3. On 02/14/22, Investigator #15 reviewed the medical records for the following patients selected as the active patient sample: Patient #1506, #1507, #1508, #1509, #1510, #1511, #1512, #1513, and #1514, to ensure that each patient's medical record, including the Master Treatment Plan (MTP), included documentation recording the patient's progress from all disciplines involved in providing active treatment modalities, The medical record review showed the following:

Patient #1506

4. Patient #1506, a 36-year-old male, was admitted voluntarily on 01/24/22, with an admission diagnosis of Alcohol Use Disorder.

a. On the Master Treatment Plan (MTP), dated 01/26/22, staff documented the Patient's Psychiatric Problem #1 Substance Abuse - Alcohol and Cannabis Use Disorder. The Nursing (RN) stated role was to encourage the use of coping skills and educate the Patient on the negative effects of alcohol use. The Physician/Provider (MD) stated role was to evaluate the Patient for symptoms or feelings of desire to relapse.

b. Review of the Daily Nursing Progress Notes for the period of 01/24/22 to 02/13/22 revealed that 21 of 23 Daily Progress Notes failed to document the Patient's progress related to the MTP goals.

c. Review of the Psychiatric Progress Notes for the period of 01/24/22 to 02/13/22 revealed that 2 of 2 Psychiatric Progress Notes failed to document the Patient's progress related to the MTP goals.

Patient #1507

5. Patient #1507, a 47-year-old female, was voluntarily admitted on 02/07/22, with an admission diagnosis of Major Depressive Disorder (MDD) and Alcohol Dependence.

a. On the MTP, dated 02/09/22, staff documented the Patient's Psychiatric Problem #1 Depressed Mood without Psychosis. The Nursing (RN) stated role was to encourage the Patient to socialize and talk about their feelings and listen without judgement.

b. Review of the Daily Nursing Progress Notes for the period of 02/07/22 to 02/13/22 revealed that 7 of 10 Daily Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/10/22, nursing staff documented that they "encouraged coping mechanisms" for the Patient, however failed to document the indication or specifics related to the coping mechanism used.

Patient #1508

6. Patient #1508, a 28-year-old male, was involuntarily admitted on 01/25/22, with an admission diagnosis of Major Depressive Disorder (MDD).

a. On the MTP, dated 01/25/22, staff documented the Patient's Psychiatric Problem #1 Depressed Mood with Psychosis. The Nursing (RN) stated role was to monitor the Patient with observations every 5 minutes to check for suicidal ideation and encourage Patient to use coping methods, such as reaching out to staff or journaling. The Physician/Practitioner (MD) stated role was to order intramuscular (IM) Zyprexa for self-harm and physical hold.

b. Review of the Daily Nursing Progress Notes for the period of 01/25/22 to 02/14/22 revealed that 10 of 11 Daily Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/07/22, nursing staff documented that they "encouraged the Patient to follow the plan of care," however failed to document the specifics of the plan of care or the interventions provided.

c. Review of the Psychiatric Progress Notes for the period of 01/25/22 to 02/14/22 revealed that 8 of 9 Progress Notes failed to document the Patient's progress related to the MTP goals.

Patient #1510

7. Patient #1510, a 37-year-old male, was involuntarily admitted on 01/28/22, with an admission diagnosis of Schizophrenia and Intellectual Disability.

a. On the MTP, dated 01/28/22, staff documented the Patient's Psychiatric Problem #1 Disturbed Thought with Paranoia. The Nursing (RN) stated role was to encourage the Patient to socialize with peers to control impulsive behavior. The Physician/Practitioner (MD) stated role was to meet with Patient to manage symptoms of psychosis.

b. Review of the Daily Nursing Progress Notes for the period of 01/28/22 to 02/15/22 revealed that 17 of 19 Daily Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/15/22, nursing staff documented that they "encouraged Patient to shower and be medication compliant," however failed to document the specifics of the plan of care or the interventions provided.

c. Review of the Psychiatric Progress Notes for the period of 01/28/22 to 02/15/22 revealed that 15 of 17 Progress Notes failed to document the Patient's progress related to the MTP goals.

Patient #1511

8. Patient #1511, a 55-year-old female, was involuntarily admitted on 02/05/22, with an admission diagnosis of Schizophrenia.

a. On the MTP, dated 02/05/22, staff documented the Patient's Psychiatric Problem #1 Disturbed Thought with Paranoia. The Nursing (RN) stated role was to encourage the Patient, provide a calm and stable environment and a regular daily schedule, encourage group attendance, and administer medications. The Physician/Practitioner (MD) stated role was to observe changes with addition and titration of Abilify and provide psychoeducation.

b. Review of the Daily Nursing Progress Notes for the period of 02/05/22 to 02/15/22 revealed that 7 of 7 Daily Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/10/22, nursing staff documented that the "Patient was worried, in a depressed mood," however failed to document interventions offered as stated in the MTP. On 02/12/22, nursing staff documented that staff will continue with "plan of care," however failed to document the specifics of the plan of care or the interventions provided.

c. Review of the Psychiatric Progress Notes for the period of 02/05/22 to 02/15/22 revealed that 5 of 7 Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/09/22, the psychiatric provider documented that the Patient was "smearing feces and would do better on 3 West," however failed to document how the move to a different unit would assist the Patient in reaching their treatment goals.

Patient #1512

9. Patient #1512, a 32-year-old male, was involuntarily admitted on 01/06/22, with an admission diagnosis of Bipolar Disorder.

a. On the MTP, dated 01/06/22, staff documented the Patient's Psychiatric Problem #1 Manic Mood with Psychosis. The Nursing (RN) stated role was to monitor Patient every 15 minutes for suicidal ideation. Monitor for Assault Precautions and Sexually Acting Out Precautions, since Patient has poor boundaries with females. The Physician/Practitioner (MD) stated role was to provide psychoeducation and psycho-evaluation, as noted for Abilify, Lamictal, and Trazadone.

b. Review of the Daily Nursing Progress Notes for the period of 02/05/22 to 02/15/22 revealed that 8 of 12 Daily Progress Notes failed to document the Patient's progress related to the MTP goals.

c. Review of the Psychiatric Progress Notes for the period of 02/05/22 to 02/15/22 revealed that 7 of 11 Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/14/22, the psychiatric provider noted that staff reported no behavioral issues and documented "will continue to monitor," however failed to document the patient's response to the recent medication changes on 02/11, or the efficacy of the medication titration.

Patient #1513

10. Patient #1513, a 51-year-old female, was voluntarily admitted on 02/02/22, with an admission diagnosis of Bipolar Disorder with Psychosis and Post Traumatic Stress Disorder (PTSD).

a. On the MTP, dated 01/06/22, staff documented the Patient's Psychiatric Problem #1 Disturbed Thought with Paranoia and Auditory Delusions. The Nursing (RN) stated role was to monitor Patient behavior, provide needed medications, and encourage patient to participate in group activities. The Physician/Practitioner (MD) stated role was to evaluate Patient for depression and delusions and increase Seroquel.

b. Review of the Daily Nursing Progress Notes for the period of 02/02/22 to 02/14/22 revealed that 12 of 12 Daily Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/06/22, nursing staff documented that the "Patient was alert and able to make needs known. Denies SI and HI (suicidal or homicidal ideation). Will continue to monitor. Will continue with treatment plan," however failed to document interventions offered as stated in the MTP, the specifics of the treatment plan that nursing staff monitored, or the Patient's progress towards treatment goals.

c. Review of the Psychiatric Progress Notes for the period of 02/02/22 to 02/14/22 revealed that 9 of 12 Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/13/22, the psychiatric provider noted that staff reported no behavioral issues and documented "will continue to monitor and observe recent changes," however failed to document what changes were recently made or the Patient's progress based on those changes.

Patient #1514

11. Patient #1514, a 72-year-old male, was involuntarily admitted on 01/25/22, with an admission diagnosis of Major Depressive Disorder (MDD).

a. On the MTP, dated 01/25/22, staff documented the Patient's Psychiatric Problem #1 Depressed Mood without Psychosis. The Nursing (RN) stated role was to monitor the Patient's behavior, to keep the Patient calm and safe, to encourage participation, and administer medications as needed. The Physician/Practitioner (MD) stated role was to evaluate Patient for symptoms of depression, as in not eating or drinking, and prescribe Zyprexa.

b. Review of the Daily Nursing Progress Notes for the period of 01/25/22 to 02/11/22 revealed that 14 of 16 Daily Progress Notes failed to document the Patient's progress related to the MTP goals. On 01/31/22, nursing staff documented that the "Patient was alert and responsive with confusion, but able to make needs known. Will continue to monitor," however failed to document interventions offered as stated in the MTP, the specifics of the treatment plan that nursing staff monitored, or the Patient's progress towards treatment goals.

c. Review of the Psychiatric Progress Notes for the period of 01/25/22 to 02/11/22 revealed that 9 of 11 Progress Notes failed to document the Patient's progress related to the MTP goals. On 02/05/22, the psychiatric provider documented that "Patient was in bed, irritable. Ate breakfast. Weight Pending. No SI (suicidal ideation), HI (homicidal ideation), or AVH (auditory/visual hallucinations). Observe recent changes," however failed to document what changes were recently made or the Patient's progress based on those changes.

12. On 02/09/22 at 9:30 AM, during an interview with Investigator #15, Registered Nurse (RN) (Staff #1507) reported that she was responsible for 9 patients for that day. Patient #1514 was one of the patients that Staff #1507 was caring for that day. Investigator #15 asked Staff #1507 about the treatment plan for Patient #1514 and the progress the Patient was making towards his treatment goals. Staff #1507 stated that she was unsure of the Patient's treatment goals and reported that the Charge Nurse completes the treatment planning documentation and updates the treatment plan. Staff #1507 stated that she documents on the Daily Nursing Progress Notes if the Patient has taken their medications and if they have suicidal ideation or behaviors. Investigator #15 remarked that the White Board (contains staffing assignments, observations and precautions levels for the unit) noted that Patient #1514 was a Fall Risk and on one to one observation and appeared to be using a wheelchair for ambulation. Staff #1507 stated that the Patient could walk, and she was unsure as to why the Patient was on those precautions and observations. She stated, "maybe he (Patient #1514) is a fall risk, but sometimes he walks and goes to the bathroom by himself."

13. On 02/09/22 at 9:45 AM, during an interview with Investigator #15, Registered Nurse (RN) (Staff #1508) was asked what the treatment goals were for a Patient in her care for the day. Staff #1508 responded that she was not sure and referred me to the Charge Nurse for that information. Staff #1508 stated that the other nurses (besides the Charge Nurse), document if the patients take their medications, have suicidal or homicidal ideation, and/or any behavioral issues.

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Based on interview and document review, the hospital failed to ensure that the Chief Medical Officer supervised the medical and psychiatric care of each patient, including medical staff credentialing and privileging, performed quality improvement activities monitoring patient care, implemented staff education programs and mechanisms for peer review, and maintained accountability to the hospital's Governing Board.

Failure to ensure that the hospital's Chief Medical Officer monitors and evaluates the quality of the services and the treatment provided by the medical staff, places the patients at risk for receiving inadequate care and may lead to potential adverse outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Plan for Provision of Patient Care," policy number L.PPPC.100, last revised 10/21, showed the following:

a. Cascade Behavioral Health is owned by Acadia Healthcare Company, Inc. Each facility, although fiscally responsible to the corporation, functions independently with a separate Governing Board, Chief Executive Office, Chief Medical Officer, and management team. The Governing Board has ultimate responsibility and authority for all patient care services. The Medical Executive Committee, as the executive body of the medical staff, is accountable to the Governing Board for clinical and administrative aspects of patient care, as well as quality improvement activities.

2. Document review of the hospital's document titled, "Cascade Behavioral Health Hospital Medical Staff Bylaws," effective date 06/21, showed the following:

a. The Medical Director shall be a member and chairman of the Medical Executive Committee.

b. The duties of the Medical Executive Committee shall be to:

i. Receive and act upon reports and recommendations from programs, committees, officers of the Medical Staff, and quality improvement activities, including reporting of the actions to the Governing Board;

ii. Coordinate the activities and policies adopted by the Medical Staff and its committees, the hospital, the Governing Board, and the Medical Director (Chief Medical Officer);

iii. Recommend to the Governing Board all matters related to appointments, reappointments, Medical Staff membership, status, Clinical Privileges, specified services, administrative remedies, quality improvement activities, and corrective action;

iv. Recommend to the Governing Board matters related to the structure of the Medical Staff and the mechanism used to review credentials and delineate individual clinical privileges;

v. Account to the Governing Board and to the Medical Staff for the overall quality, uniformity, and efficiency of the medical care rendered to patients;

vi. Represent and act on behalf of the Medical Staff between meetings of the Medical Staff, subject to the limitations imposed by these Bylaws;

vii. Take all reasonable action necessary to ensure that each Medical Staff peer evaluation, FPPE/OPPE, and quality improvement activity is performed;

viii. Make recommendations to the Governing Board of the kinds, type, and amounts of data to be collected and evaluated to allow the medical staff to conduct an evidence-based analysis of the quality of professional practice of its members; and

ix. Submit recommendations to the Governing Board for changes in the Medical Staff Bylaws, Rules and Regulations, and other organization documents pertaining to the Medical Staff;

x. Communicate proposals to adopt or amend a rule, regulation, or a policy to medical staff members;

xi. Communicate amendments to Bylaws, rules, regulations and policy to medical staff members.

xii. Meetings - Medical Executive Committee meetings shall meet at least four times during the year and maintain minutes as is appropriate for each meeting.

3. Review of the Medical Executive Committee meeting agendas and minutes for 2021 showed the following:

a. On 04/30/21, the Medical Staff and Medical Executive Committee met. For each meeting, Investigator #15 found documentation of the meeting agenda, meeting attendance, and subsequent meeting minutes. Agenda items discussed and voted on included the presentation and review of several psychiatric and internal medicine providers. Additional agenda items discussed included Utilization Review and Quality Performance Improvement Projects, including audit data.

b. On 09/27/21, a Medical Executive Committee meeting was facilitated by the Corporate Director of Risk (Staff #1510). Based on the agenda provided by the facility to the investigators, the only topic discussed was the presentation of credentialing and privileging summaries for several psychiatric and internal medicine providers and the vote to approve, listing three members of the Medical Executive Committee indicating their approval. There was no documentation of meeting attendance. There were no meeting minutes provided. Based on the documentation provided, there was no further discussion of additional topics, including Quality Performance Improvement Projects, data collection or review, policy and procedure review, or peer reviews.

c. On 11/17/21, a Medical Executive Committee meeting was facilitated by the Chief Operating Officer (Staff #1516). The only topic discussed was the presentation of credentialing and privileging summaries for several psychiatric and internal medicine providers. There were no meeting minutes provided. Based on the documentation provided, there was no further discussion of additional topics, including Quality Performance Improvement Projects, data collection or review, policy and procedure review, or peer reviews.

4. On 02/11/22, at 1:45 PM, during an interview with Investigator #12 and Investigator #15, the Chief Medical Officer (Staff #1512) stated that the Medical Executive Committee meetings are held quarterly, however there was some discussion to increase the frequency of the meetings. When the investigators asked Staff #1512 about the Medical Executive Committee members, he stated he believed that the previous Medical Staff President, the Chief Operating Officer and himself were part of the committee, but was unsure of the other members of the committee. He stated that he would have to look that up to confirm.

The investigators asked Staff #1512 about how, in his role as the Chief Medical Officer, ensures that the Medical Executive Committee participates in the appointments, reappointments, Medical Staff membership, status, credentialing and clinical privileging, quality improvement activities, and corrective action. Staff #1512 stated that credentialing and privileging is an informal process. Typically, he first talks with other medical staff about the provider seeking credentialing. Staff #1512 also stated that it had been a while since he was involved in the process, and he was not here for the last one. Staff #1512 reported that once the Medical Staff approves, the application is forwarded to the Medical Executive Committee. Staff #1512 stated that he believed that was all that was involved in the process. He was unsure if the Governing Board is part of that process.

In response to questions regarding the CMO's responsibility for the overall quality of care that the patients receive, Staff #1512 stated that the team is constantly meeting, for example the daily flash meetings, coaching providers and talking as a group every day. They are evaluating quality and performing chart audits and peer reviews. Investigators noted that the Medical Staff meeting minutes were not provided when requested. Staff #1512 stated that they would have to get better about documenting the staff meetings, chart audits and peer reviews. Staff #1512 was unable to speak to questions regarding current Quality performance improvement projects and action plans, or how the Medical Executive Committee interfaces with the Governing Board.

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