HospitalInspections.org

Based on interview and record review, the facility failed to ensure that the medical staff provide quality of care to patients. There was no documentation of proctoring for six (6) physicians appointed to the medical staff.

Findings:

A review of 6 physician files appointed to the medical staff revealed no documentation of proctoring as stipulated in the medical staff by-laws.

At the same time during an interview, the medical staff coordinator stated there was no documentation on file of any proctoring completed for the 6 physicians appointed.

A review of the medical staff by-laws revealed, "except as otherwise recommended by the Medical Executive Committee and approved by the Governing Board, all new appointments to the Medical Staff or Affiliate Staff shall be provisional for a minimum of twelve (12) months, during which the submission of proctor reports as defined below on not less than three (3) patients treated by the provisional staff member is provided."

Based on interviews and review of records, the facility failed to
ensure treatment plans were complete and included all required disciplines for five (1, 2, 3, 4, and CRR1) out of five records reviewed. The facility failed to ensure that concerns identified upon admission were addressed and care planned for. The facility failed to modify the five patients' (1, 2, 3, 4, and CRR1) treatment plans when improvements, failures to improve, and other changes in the patients' conditions were identified. The facility further failed to document assessments and interventions to formulate a chronological picture of two patients' (7 and 8) progress, or absence of progress, towards goals established in their treatment plans.


Findings:

A review of clinical records for Patients 1, 2, Patients 3, 4, and CRR1 revealed incomplete "Multidisciplinary Treatment Plan" (MDTP). "Treatment Team Interventions," section on the MDTP, contained sections for individual disciplines to document their plans for treating the patient's identified problem, and the specific behaviors and/or symptoms their plan targets. Under,"physician," of the "Discipline" section, the pre-printed intervention provided the option to "order or titrate the dosage" [of a medication], followed by a section that asked to identify the targeted symptoms or behaviors.

In all cases Patients 1, 2, 3, 4, and CRR1), the physicians failed to complete their portion of the treatment plans, which called for the specific medication(s) the physicians planned as their interventions, and the behaviors or symptoms those medications were expected to treat.

For example:

1. Patient 3 was admitted with delusional thoughts and behaviors. The Multidisciplinary Treatment Plans (MDTP) were initiated for: Psychotic Behavior, Placement, and Seizure Precautions. None of the physician's sections on those forms, though dated and signed, included the medication interventions or the intended symptoms or behaviors the medication(s) were to target.

2. Review of Patient 4's clinical record produced documents that contained plans for the patient's treatment while in the facility.

The MDTP entitled, "Potential for Seizures," was opened 4/8/11.
On Patient 4's MDTP for Seizures, the physician signed and dated on his designated section of the form, but the planned intervention of medication was not identified, and the symptoms/behaviors to be targeted were not addressed.

The MDTP for Patient 4's "Manic Behavior," comprised of the same format, was opened 4/13/11. The physician section on the form was signed and dated, but the medication interventions and targeted behaviors were not completed.

On a MDTP for Depressed Mood with Suicidality, the physician signed and dated Patient 4's plan, but the medication interventions and targeted behaviors were not filled out.

2. Various documentation in the clinical record, including RN Shift Progress Notes, described Patient 4's continuing behavior as, among other things, agitated, anxious, restless, hostile, and paranoid; the same behaviors the patient presented upon admission.

Review of the clinical record revealed the initial plans of care on the MDTP were not re-evaluated or modified for alternative interventions to address Patient 4's progress, or failure to progress, between 4/7/11 and 4/25/11.

3. Additional entries in Patient 4's clinical record noted Patient 4 was non-compliant with medications and diet. There was no documentation a plan had been developed to address either issue.




25524


4. During an observation on the Inter Treatment Unit (ITU), April 20, 2011, at 10:55 a.m., Patient 7 came to the nurses' station. Patient 7 was wearing a button up sweater and her left arm/wrist was poked from between two buttons. Patient 7 had made a sling using her sweater. She had on dirty jeans with the hem torn, her feet were dirty and black, and her hair was dirty uncombed. Staff G went to the door to inquire what Patient 7 needed. Patient 7 stated that she required her post trauma medications. Staff G asked Patient 7 why she was not in group. Patient 7 stated she was doing what she was supposed to do: "rest." Patient 7 stated that her arm hurts.

The clinical record was reviewed on April 20, 2011. According to the Application for 72 Hour Detention for Evaluation and Treatment, dated March 14, 2011, Patient 7 was a danger to others (DTO) and gravely disabled.
A review of several plans of care entitled, Psychotic Behavior, dated March 14, 2011, revealed Patient 7's goal was to make no statement regarding casting parts of body. The interventions included to attend "process group" seven times per week, to explore feelings/behaviors related to psychotic behavior and increase positive coping skills.

A plan of care entitled, "Aggressive/Assaultive Behavior," dated March 14, 2011, indicated the patient's goal was to refrain from violent behavior. The interventions included to attend anger management group for seven days per week to decrease impulsivity and increase coping skills. The plan of care did not specify the impulsivity behavior.

The Treatment Plan Review/Weekly Summary Progress Report notes, dated March 23 through March 30, 2011, did not give a chronological picture of how Patient 7 was progressing towards her treatment plans.

A review of the Daily Group Progress Notes dated March 17 through March 20, 2011 indicated the patient did not attend the group. Due to this patient's inability to attend treatment groups today, staff met with them and discusses the Active Treatment Handout titled Alterations in Mood Manic handout given. There was no documentation that Patient 7 was able to process the information. The progress notes did not give a chronological picture of how the patient was progressing toward the accomplishment of her individualized goals in the treatment plan.

5. A review of the Inpatient Admission Nursing Assessment, dated March 14, 2011, at 8 p.m., indicated Patient 7 was wearing a sling on her left arm and wore a left leg brace. During the admission assessment, nursing documented Patient 7 verbalized several times that she had a left shoulder fracture. Further review revealed no evidence an assessment of the left arm had been conducted.

During an interview with the director of nurses (DON), on April 21, 2011, at 10:20 a.m., she reviewed the clinical record and stated the Progress Record notes by the physician (undated) indicated " shoulder in sling allows very limited examination." The physician did not specify which shoulder was in the sling. She further stated Patient 7 was seen at an acute care hospital and medically cleared. She did not expand on the correlation between the patient's medical clearance and assessments of the patient's left arm and leg. She also stated "No, order for X ray."

During an interview with Staff H, on April 22, 2011, at 9:30 a.m., he reviewed the clinical record and was unable to find documentation of an assessment for April 20, 2011. Staff H stated there was no assessment for the April 17, 2011 shoulder pain. Staff H further stated Patient 7's physician had ordered an x ray of the shoulder, and there was no assessment of the shoulder.

During an interview with Staff I, on April 22, 2011, at 10:15 a.m., she stated Patient 7 came with the sling and should have been cleared.

A review of a medication treatment record dated April 15, 2011, at 4:30 p.m.,
indicated Patient 7 was given Tylenol 650 mg. for left shoulder pain. A review of the Medication Administration Record start date April 13, 2011 indicated Tylenol 650 mg. by mouth every 4 hours as needed for headache. There was no order for the left shoulder pain.

A review of a Progress Record, not dated, indicated patient had her shoulder in a sling.

A review of a RN Shift Progress Note dated April 17, 2011, at 8:30 p.m., indicated "arm remains in sling and does complain of shoulder pain." There was no assessment why Patient 7's arm was in the sling.

A review of an acute care emergency room form dated March 14, 2011 indicated Patient 7 was given medical clearance prior to being sent to the psychiatric facility. According to the review systems, Patient 7 had full range of motion. There was no mention of a sling.

A review of a facility's policy and procedure titled Nursing Assessment and Reassessment of Patients dated January 1, 2001 indicated an effective and comprehensive nursing assessment of each patient's needs is made in order to determine and provide an optimal level of nursing care. Furthermore, each patient is re-assessed by a registered nurse daily (Q 24 hrs), as needed (prn), and as the patient's condition/needs warrant. The purpose of the Treatment Planning Meetings was to assess and reassess the patient's condition, treatment plan, and progress goals. There was no documentation of re-assessments of Patient 7's shoulder. There were no reassessments of Patient 7's shoulder or revisions to the plan of care to include the sling.

A review of a policy and procedure entitled, "Pain Assessment and Management," dated January 1, 2001, stipulated the licensed nursing staff will assess and periodically reassess the patient for pain.

6. The clinical record of Patient 8 was reviewed on April 21, 2011. The Application for 72 Hour Detention for Evaluation and Treatment indicated Patient 8 was admitted to the facility on March 19, 2011 on a 5150 for danger to himself and gravely disabled.

A plan of care titled Aggressive/Assaultive Behavior dated March 19, 2011 indicated the patient had a physical altercation at the board and care where the patient resided. The goal for the patient was to refrain from violent, agitated or destructive behavior. The staff's interventions included to monitor for inappropriate behavior to decrease feelings of aggression once per shift, attend group to decrease impulsivity and increase coping skills. However, there was no specific description of the inappropriate behavior or the decreased impulsivity and increased coping skills.

The physician's interventions were blank. A review of the admitting physician's order dated March 19, 2011 indicated suicide and assaultive precautions with supervision of every 15 minute round checks. The plan of care did not specify the inappropriate behavior of feelings or aggression behavior.

A plan of care titled Depressed Mood with Suicidal manifested by suicidal thoughts "at times," dated March 19, 2011, indicated the patient will identify three activities that will ensure safety in the event of a crisis. The staff's interventions included; "to monitor changes in behavior and feeling unsafe," for the patient to attend groups to decrease depression symptoms and increase his coping skills. The interventions for suicide precautions were left blank. The plan of care did not described the triggers to monitor for changes in the behavior and the feeling unsafe.

A plan of care titled Psychotic Behavior dated March 28, 2011 indicated the patient will verbalize benefits of medications and show ability to accomplish self care activities without staff prompts. The staff's interventions included; to administer medications, patient to attend groups to allow patient to explore his feelings/behavior related "to psychotic thinking and visual hallucinations and to increase orientation." However, there were no specifics regarding what "psychotic thinking and visual hallucinations."

A review of a facility's policy and procedure titled Interdisciplinary Treatment Plan dated January 1, 2001 indicated all patients are to have an individualized comprehensive interdisciplinary treatment plan which included long and short term goals, the methods and strategies utilized, staff and patient responsibilities for reaching the goals. The treatment plan is formally evaluated at the Weekly (or more frequently as required) Treatment Planning Meetings. Each problem is reviewed and documented daily. Changes in the treatment plan are made accordingly based on the treatment planning process and needs of the patient and response to interventions.