HospitalInspections.org

Based on record review and interview, the attending psychiatrist failed to write progress notes which specifically addressed patient progress towards treatment goals for 6 of 6 active sample patients on Unit 306 (306N, 306S, 306T, 306U, 306V, and 306W), and response to medication for 5 of 6 active sample patients on Unit 306 (306N, 306S, 306T, 306U and306V). This failure impedes the treatment team's ability to assess or evaluate patients' response to the treatment plan.
Findings are:

A. Record Review

1. Patient 306N

a) "Psychiatrist Progress Note" dated 11-17-09 at 9:000 [sic] a.m. (Preprinted form allowing for free-form additions under specific headings):

"Treatment Current Medications, including absence/presence of side effects, therapeutic benefits, and any recent changes with rationale for the changes:" Typed into this area was the following: "Olanzapine Zydis 15mg po qd for psychosis, Clonazepam 1mg po bid for anxiety, No change in psychotropics." [No assessment of response to treatment was included.]

"Significant lab values:" Typed into this area was the following: "WBC 8.0, ANC 5.0, Platelets 169, Chol 162, TGs 68, TSH 1.39, CRT 0.7" [No interpretation of the results was included.]

"Medical Issues (if any):" Typed into this area was the following: "Sinus bradycardia, Left bundle branch block, nasal septal deviation, and conductive hearing loss in left ear."

"Patient attended:" "supportive therapy 4 of 4 scheduled sessions, 15 minutes per session; medication education, 4 of 4 scheduled sessions, 60 minutes per session; community meetings, 20 of 20 scheduled sessions, 30 minutes per session."

"Target Symptoms (Current):" Checkmarked for inclusion was: "Thought Disorder; Negative Sx [symptoms]of Schizo. [Schizophrenia]; Sexually Inappropriate behaviors; Poor insight/judgment."

"Treatment Focus:" Checkmarked for inclusion was "to diminish patient's psychotic symptoms; to enhance medication education and illness self-management and other, specify below: (area left blank)."

"Outcome: Describe current behavior, mental status, response to treatment, including the patient's perception of medication effects." Typed into the space below was the following information: "[306N] has been attending therapeutic groups and activities. [306N] has poverty of thought with disorganization. [306N]'s ability to participate in the groups is limited. Patient continues to exhibit sexually inappropriate behavior like kissing female staff on their hands or blowing kisses. [306N] exposed themselves to the dental hygienist when [306N] was in the dental chair. On 3-26-09 [306N] kissed a staff on their shoulder. [306N] episodically, albeit less, makes efforts to escape. [306N] wishes to go to JFK airport for a job and skydiving. [306N] needs of continued inpatient level of care. Now [306N] believes that he/she needs blood orally, either in a cake form or with cream, as regularly blood is drawn from him."

"BPRS score:" (left blank)

"Plan:" Checkmarked for inclusion was "to continue current medication combination; to monitor side effects and titrate the dosage in accordance with therapeutic response; to treat side effects; to continue current objective and method."

"Patient understands need for change of medication and potential risks and benefits:" marked "yes."

"Family education/contact (describe):" typed into the response area is the following: "Family members me [sic] with team on family day, 9-13-09."

"Discharge/Transfer Plan:" marked "Not ready for discharge/Transfer" Signed by MD306

Although the note recounted lab values and patient presence at groups, there was no assessment of progress or lack thereof towards any specified goal, nor was there a plan to change treatment based on progress or lack thereof.

b) "Psychiatrist Progress Notes" dated 12-15-09 at 9:000 [sic] am noted exactly the same information as described in Section "a)" above, with the addition under the "Significant lab values" area of "HgbA1c 6.0".

2. Patient 306S

a) "Psychiatrist Progress Note" dated 11-10-09 at 9:00 a.m. (Preprinted form allowing for free-form additions under specific headings):

"Treatment Current Medications, including absence/presence of side effects, therapeutic benefits, and any recent changes with rationale for the changes." Typed into this area was the following: "Clonazepam 0.5mg po twice a day for Anxiety...Clozapine 100mg po qam and 350mg qhs for Psychosis. Constipation. No change in psychotropics."

"Significant lab values:" typed into this area was the following: "WBC 8.7, ANC 4.9, Platelets 301, Chol 136, Lith. 0.88, TGs 246, RPR -ve, HgbA1C 5.9".

"Medical Issues (if any):" typed into this area was the following: "Overweight, Constipation, Dyslipidemia, IDDM, Hypertension, Metabolic Syndrome."

"Patient attended:" "supportive therapy 4 of 4 scheduled sessions, 15 minutes per session; medication education, 4 of 4 scheduled sessions, 60 minutes per session; community meetings, 20 of 20 scheduled sessions, 30 minutes per session."

"Target Symptoms (Current):" No sections were checkmarked for inclusion

"Treatment Focus:" Checkmarked for inclusion were: "to diminish patient's psychotic symptoms; to enhance medication education and illness self-management"

"Outcome: Describe current behavior, mental status, response to treatment, including the patient's perception of medication effects." Typed into the space below was the following information: "patient shows disorganized thinking, irritable mood and paranoid ideation. [306S] has poor insight into his/her sexual behavior, needs of his medical problems and needs in the community. Therefore [306S] needs continued inpatient care."

"BPRS score:" (left blank)

"Plan:" Checkmarked for inclusion was: "to adjust medication as follows...:" Typed into the space was "Patient is resistant to any change in psychotropics...to monitor side effects and titrate the dosage in accordance with therapeutic response; to treat side effects; to monitor blood level of Lithium and Clozapine as indicated; to continue current objective and method." "Patient understands need for change of medication and potential risks and benefits:" Marked "yes." "Family education/contact (describe):" left blank. "Discharge/Transfer Plan:" Marked "Not ready for discharge/Transfer."

Signed by MD306

Although the note recounted lab values and patient presence at groups, there was no assessment of progress or lack thereof towards any specified goal, nor was there a plan to change treatment based on progress or lack thereof.

b) "Psychiatrist Progress Notes" dated 12-08-09 at 9:00 am had noted exactly the same information as described in Section "a)" above with the addition under the "Significant lab values" area of "WBC 7.4, ANC 3.4, Plt. 313, Crt. 0.7, Chol 119, TGs 215, Cloz. 417, Lith. 0.88, RPR -ve [negative], HgbA1C 5.9, CPK 204."

c) "Psychiatrist Progress Notes" dated 01-05-10 at 9:00 am had noted exactly the same information as described in Sections "a)" and "b)" above, with the addition under the "Significant lab values" area of "WBC 7.8, ANC 4.0, Plt. 292, Crt. 0.9, Chol 114, TGs 208, Cloz. 396, Lith. 0.83, RPR -ve [negative], HgbA1C 5.9, TSH 2.9, Hct 37.8, CPK 204."

3. Patient 306T

a) "Psychiatrist Progress Notes" dated 11-05-09 at 9:00 am; 12-03-09 at 9:00 am; and 12-3-09 at 9:00 am. All three progress notes had exactly the same outcome and plan noted for each entry as follows:

"Treatment Focus:" Check marked for inclusion were: "to diminish patient's psychotic symptoms; to enhance medication education and illness self-management."

"Outcome: Describe current behavior, mental status, response to treatment, including the patient's perception of medication effects." Typed into the space below was the following information: "During the past month, patient has been in good control, able to care for his/her needs and follow directions. [306T] has been compliant with medications and has been attending therapeutic groups and activities in the unit and in the treatment mall with other peers. [306T] has not shown any aggressive or sexually inappropriate behaviors. His/her thought content shows persistence of illogical thinking and grandiose beliefs. He/she requires continued inpatient level of care, as due to grandiose ideations he/she does not participate, realistically, in discharge planning."

"BPRS score:" (left blank)

"Plan:" Checkmarked for inclusion was "to adjust medication as follows:" Typed into the space was "Titrate Topiramate if needed...to monitor side effects and titrate the dosage in accordance with therapeutic response; to treat side effects; to continue current objective and method." "Patient understands need for change of medication and potential risks and benefits:" marked "yes" "Family education/contact (describe):" Typed in "None." "Discharge/Transfer Plan:" Marked "Not ready for discharge/Transfer."

Signed by MD306

There was no plan to change treatment based on lack of progress in ability to plan for discharge.

3. Patient 306U

a) "Psychiatrist Progress Note" dated 11-17-09 at 9 am. (Preprinted form allowing for free-form additions under specific headings):

"Treatment Current Medications, including absence/presence of side effects, therapeutic benefits, and any recent changes with rationale for the changes." Typed into this area was the following: "Olanapine Zydis 15 ngs po twice a day for psychosis; Lithium Carbonate 600 mgs po bid for mood-stability; Lorazepam 2 mgs po prn nopo [sic] for anxiety. No side-effects noted. No changes in medication regimen since patient has been transferred from CREF Unit."

"Significant lab values:" Typed into this area was the following: "WBC 7.2, ANC 2.8, Platelets 251, Chol 166, Lithium level 0.93, TGs 150, TSH 1.36."

"Medical Issues (if any):" Typed into this area was the following: "Hepatitis C, Chronic low ANC"

"Patient attended:" "supportive therapy 4 of 4 scheduled sessions, 15 minutes per session; education, 4 of 4 scheduled sessions, 60 minutes per session; community meetings, 20 of 20 scheduled sessions, 30 minutes per session."

"Target Symptoms (Current):" No sections were checkmarked for inclusion

"Treatment Focus: checkmarked for inclusion was: "to diminish patient's psychotic symptoms; to manage agitation; to stabilize mood; to enhance medication education and illness self-management; to understand the need for sobriety."

"Outcome: Describe current behavior, mental status, response to treatment, including the patient's perception of medication effects" Typed into the space below was the following information: "Though not psychotic patient exhibits episodic agitation and passively participates in treatment modalities. He/she has poor insight into aftercare needs."

"BPRS score:" (left blank)

"Plan:" Checkmarked for inclusion was: "to adjust medication as follows: typed into the space was 'Lithium depending upon blood level and clinical need'; to monitor side effects and titrate the dosage in accordance with therapeutic response; to treat side effects; to monitor blood level of Lithium as indicated; to continue current objective and method" "Patient understands need for change of medication and potential risks and benefits:" Marked "yes." "Family education/contact (describe):" Typed into the blank area was: "By phone."

Signed by MD306

b) Psychiatrist Progress Note dated 12-15-09 at 9 am. This was exactly the same as Section "a)" noted above.

4. Patient 306V

a) "Psychiatrist Progress Notes" dated 11-24-09 at 9:00 am and 12-22-09 at 9:00 am. Both progress notes had exactly the same outcome and plan noted for each entry as follows:

"Treatment Focus:" Checkmarked for inclusion were: "to diminish patient's psychotic symptoms; to enhance medication education and illness self-management; to participate in discharge planning."

"Outcome: Describe current behavior, mental status, response to treatment, including the patient's perception of medication effects:" Typed into the space below was the following information: "Patient has been compliant with his medications and has remained in good behavioral control. Though he lacks spontaneity he is pleasant on approach. He/she denies any thoughts of hurting self or others. Patient attends groups and activities in the treatment mall but his/her ability is limited by negative symptoms. However he/she continues to participate in discharge planning."

"BPRS score:" (left blank)

"Plan:" Checkmarked for inclusion was: " to monitor side effects and titrate the dosage in accordance with therapeutic response; to monitor blood level of Lithium as indicated; to assess readiness for discharge; to treat side effects; to continue current objective and method" "Patient understands need for change of medication and potential risks and benefits:" Marked "yes." "Family education/contact (describe):" Typed in "Patient has no family contact."

Signed by MD306

5. Patient 306W

a) "Psychiatrist Progress Note" dated 11-05-09 at 9:00 am. (Preprinted form allowing for free-form additions under specific headings):

"Treatment Current Medications, including absence/presence of side effects, therapeutic benefits, and any recent changes with rationale for the changes." Typed into this area was the following: "Benztropine 0.5 mg po twice a day for bradykinesia, Clonazepam 1 mg twice a day for anxiety, haloperidol 5 mgs po am and 10 mgs po qhs for psychosis, Lorazepam 1 mg po prn nopo [sic] q6hours for anxiety. No change in psychotropics."

"Significant lab values:" Typed into this area was the following: "WBC 4.7 ANC 2.5 Platelets 112, TSH 1.69, Chol 205, TGs 79, CRT 0.9, PSAi 1.1, RPR -ve , HgbA1C 6.0."

"Medical Issues (if any):" typed into this area was the following: "Sickle Cell Trait, Onchomycosis, CT of Chest: Aneurysm of Ascending Aorta, Bilateral Renal Cysts, Hypertension, Bradykinesia, Metabolic Syndrome."

"Patient attended:" "supportive therapy 4 of 4 scheduled sessions, 15 minutes per session; medication education, 4 of 4 scheduled sessions, 60 minutes per session; community meetings, 20 of 20 scheduled sessions, 30 minutes per session."

"Target Symptoms (Current):" Checkmarked symptoms included: "Delusions, Irritable mood, negative symptoms of schizophrenia, Substance Abuse, Aggression, poor insight into aftercare."

"Treatment Focus:" Checkmarked out for inclusion was: "to diminish patient's psychotic symptoms; to stabilize mood; to enhance medication education and illness self-management; to understand the need for sobriety."

"Outcome: Describe current behavior, mental status, response to treatment, including the patient's perception of medication effects" Typed into the space below was the following information: "Patient has remained psychotic, with delusions of having invented chemical formulas for all the famous soft drinks etc. hallucinations and disorganized thinking. His/her loud outbursts have almost ceased and have responded to increased dose of Haloperidol. He/she is compliant with medications." [This is repeated unchanged in the note the following month (see "b)" below)].

"BPRS score:" (left blank)

"Plan:" Checkmarked for inclusion was: "to adjust medication as follows:" The space was left blank. "to monitor side effects and titrate the dosage in accordance with therapeutic response; to treat side effects; to continue current objective and method." "Patient understands need for change of medication and potential risks and benefits:" Marked "yes." "Family education/contact (describe):" Typed into the response space: "None."

Signed by MD306

b) Psychiatrist Progress Note dated 12-03-09 at 9:00 am. This was exactly the same as Section "a)" except for the addition of the following statement under "Plan:" "Dronabinol to be tried for refractory psychosis as per medical director's review."

c) Psychiatrist Progress Note dated 12-30-09 at 9:00 am. This was exactly the same as Sections "a)" and "b)" except for the following addition under the section for "Treatment:" "Dronabinol 10 mgs po twice a day for refractory psychosis. Dronabinol was added after review by medical director."

B. Interview

The Clinical Director was interviewed by the surveyors on 01/13/10 at 10:30 am. She agreed with the findings noted above and stated "This isn't acceptable."

Based on review of medical records from Ward 306, policy review, and interview, the social work staff failed to write thirty (30) day progress note summaries which contained information to specifically address patient progress towards treatment goals and safe discharge planning for 6 of 6 sampled patients (Patients 306N, 306S, 306T, 306U, 306V, and 306W). This failure impedes the treatment team's ability to assess or evaluate the patient's response to the treatment plan.

Findings are:

A. Record Review:

1. Social worker SW306 wrote the following progress note summary on 11/20/09 regarding patient 306N: "[306N] continues to kiss the wrist of female staff when [306N] gets the opportunity. Patient constantly enquires about getting discharged to the community....wants to work in the JFK airport after discharge. Patient exposed self at the clinic few months ago. [306N] remains intrusive. [306 N] constantly asking the same questions during all the community meetings. Patient continues to attempt to touch or kiss the hands of female staff. Patient attends the treatment mall groups and at times talks about appropriate behavior towards females. Often [306N] would answer 'I do not know.' Patient also has a history of trying to elope from the unit. [306N] lacks insight into (306N)'s illness. Patient's mother is supportive but unable [sic] take him upon discharge. The family came for the family day on 8/13/09 and had discussion with the treatment team."

Social worker SW306 wrote a progress note summary on 12/18/09 regarding patient 306N that virtually repeated the same content at the progress note summary of 11/20/09. The notes contained factual information, but did not relate to treatment goals, or to any proposed change in plans to assist the patient to progress towards discharge.

2. Social worker SW306 wrote the following progress note summary on 11/27/09 regarding patient 306S: "There are no major changes in patients [sic] behavior during this period. [306S] remains compliant with medication, treatment and unit routine. Patient remains calm and no inappropriate behaviors reported during the past month. Patient comes to the individual sessions and groups but does not want to talk more about...issues. (306S) does not interact much with peers and staff unless needed. [306S] does not normally initiate a conversation with peers or staff. [306S]'s family has not contacted (306S) during the last month. Of late, the patient shows some interest in generalized discussion. Of late patient shows some interest in talking about discharge matters during the treatment mall sessions. Patient lacks insight into (his/her)'s illness."

Social worker, SW306 wrote a progress note summary on 12/24/09 regarding patient 306S that virtually repeated the same content at the progress note summary of 11/27/09. The notes contain factual information, but do not relate to treatment goals, or to any proposed change in plans to assist the patient to progress towards discharge.

3. Social worker SW306 wrote the following progress note summary on 11/15/09 regarding patient 306T: "Patient remained very loud and demanding at times during the last month. [306T] continue to remain delusional. Oflate [sic], [306T] talks about...new ideas every time. [306T] expresses the thoughts that [306T] has the power of telepathy, and magic is the only cure of [306T]'s mental illness. [306T] is very polite and respectful in dealing with staff and peers. [306T] is also pleasant and cooperative and compliant with rules and regulations on the unit. At present, patient is agreeable in taking medications after discharge. Patient is able to discuss past crimes but has no remorse about the past crimes committed. [306T] stated that [306T] killed [306T]'s father in self defense and it is not a crime to kill someone in self defense. Patient normally has some grandiose thoughts during the community meetings and group sessions. He often talks about the magic store in Bronx where [306T] could buy magical portions [sic]. Oflate [sic] patient does not call [306T]'s brother as he moved out of his previous place and has no contact number of address. Worker send [sic] a letter to [306T]'s brother in his old address requesting him to provide whereabouts but the letter returned. Patient has very little insight into...illness. "

Social worker SW306 wrote a progress note summary on 12/18/09 regarding patient 306T that virtually repeated the same content at the progress note summary of 11/15/09. The notes contained factual information, but did not relate to treatment goals, or to any proposed change in plans to assist the patient to progress towards discharge.

4. Social worker SW306 wrote the following progress note summary on 11/27/09 regarding patient 306U: "[306U], oflate [sic] comes to the staff at times when [306U] feels angry or threatened and no aggressive behaviors noted. [306U] was transferred from CREF to unit 306 for continuation of care and treatment. Patient came to treatment team meeting and appeared to be interested in talking about [306U]'s illness and future plans, etc. Pt. remains compliant with medications, but constantly refuses to comply with unit rules and regulations. Patient has limited insight into [306U]'s problems. Patient spends most of [306U]'s time sleeping on the unit. Patient attends treatment mall but with limited participation. Pt. denies any manic or depressive symptoms. Pt. has low frustration tolerance. He was inviolved [sic] in physical altercation with another resident in the CREF during this review period. Patient has poor insight into substance abuse issues, and tries to minimize it. He was screened by PHP (partial hospitalization program) recently but not accepteed [sic]. Worker will continue to meet with patient and try to improve insight into issues. Discharge plans discussed with patient and (306U) expresses motivation for discharge at this time. Pt. went for placement interview at Bronx TLR, but was not accepted. Pt. continues to need further stabilization."

Social worker SW306 wrote a progress note summary on 12/24/09 regarding patient 306U that virtually repeated the same content at the progress note summary of 11/27/09. The notes contained factual information, but did not relate to treatment goals, or to any proposed change in plans to assist the patient to progress towards discharge.

5. Social worker SW306 wrote the following progress note summary on 11/20/09 regarding patient 306V: "[306V] continue [sic] to be unable to have a reality based convsation (sic) in an appropriate manner. [306V] is compliant with medications and treatment. Patient remains isolated and interacts minimally with staff and peers. [306V] is able to verbalise [306V]'s needs. [306V] has been to the Orangetown criminal court recently regarding the assault of a peer and court has given [306V] a ACD for a year. Patient remains calm at present. [306V] remains isolated and does not normally interact (sic) peers or staff unless it is needed. Oflate [sic] patient does not get angry even when peers invade his personal space. Oflate [sic], patient shows slight improvement of ADL skills. Patient attends group sessions but does not participate. [306V] remains calm during the sessions but unable to make a reality based conversation during the sessions. Patient expresses some disorganized thoughts often when questions are asked. Pt. does not have any family contact. [306V] has very limited insight into [306V]'s problems. A social security appt was scheduled on 7/7/08 and medically approved of 7/31/08. A packet was sent to Hedgewood adult home but they have not called (306V) for interview because of (306V)'s history."

Social worker SW306 wrote a progress note summary on 12/18/09 regarding patient 306V that virtually repeated the same content at the progress note summary of 11/20/09. The notes contain factual information, but do not relate to treatment goals, or to any proposed change in plans to assist the patient to progress towards discharge.

6. Social worker SW306 wrote the following progress note summary on 11/20/09 regarding patient 306W: "Patient appears calmer and easier to redirect during the last month. [306W] is able speak [sic] in a realistic manner for a few minutes at times during the group sessions. Patient generally remains disorganized. [306W] is unable to discuss symptoms and illness without reference from internal stimuli during the group sessions. [306W] likes to attend to the individual sessions and express [306W]'s thoughts. Pt's thoughts are disorganized, speech is pressured, rapid and mostly loose. [306W] gets loud and agitated when (306W) is upset. Pt is in denial of [306W]'s mental illness. Insight and judgment are impaired. Pt. remains psychotic. [306W] needs further stabilization. Pts [sic] identity still remains a mystery."

Social worker SW306 wrote a progress note summary on 12/18/09 regarding patient 306W that virtually repeated the same content at the progress note summary of 11/20/09. The notes contained factual information, but did not relate to treatment goals, or to any proposed change in plans to assist the patient to progress towards discharge.

B. Policy:

The Rockland Psychiatric Center, Social Work Department Policy & Procedure Manual, Section 5.2, last revised 10/1998, entitled, "Case Recording" states the following procedure for social work progress notes, including progress note summaries:

"Social Workers document all interactions with patients, their families and significant others, as well as service contacts with other health and social systems on behalf of the patients. These recordings are found in the "Progress Notes" section of the patient's chart...These recordings also reflect the stage of progress or lack of it in working with patients according to the goals and objectives of the individual treatment plan. Typically, progress notes reflect the behavior of the patient during the particular treatment plan. Typically, progress notes reflect the behavior of the patient during the particular treatment intervention, the specific goal of the intervention, time frame and outcome...."

C. Interview:

The Social Work Director was interviewed on January 13, 2010 at 3:15pm in her office. She was shown the progress note summaries of patients 306N, 306S, 306T, 306U, 306V, and 306W). She stated that she "agreed that the social work progress notes summaries did not provide any individualized updated information that summated clinical contacts and progress as required within the social work case recording policy (Section 5.2)." She agreed that the same general wording from one monthly progress note summary was repeated at the next 30 day summation period. She stated that these progress note summations did not reflect particular treatment interventions, the specific goals of interventions, time frames and outcomes as defined within the social work policy on case recording. She also stated that the six (6) selected progress note summaries "lacked individualized focus and were missing positive strengths of the patient from the social work and patient interaction."