HospitalInspections.org

Based on document review and interview, the facility failed to ensure that policies related to the reassessment of skin conditions occurred for 2 of 2 patients with a "rash" noted at the time of admission (patients #1 and #3), and failed to follow facility protocol for the checking of personal belongings/effects at the time of discharge for 3 of 3 discharged patients (patients #1, #2, and #3).

Findings:
1. Review of the policy "Reassessment & Change is (sic) Condition", no policy number, last revision date of 3/6/14, indicated:
a. Under "Policy", it reads: It is the policy of Options Behavioral Health System to assess the patient at time of admission, when transitioning to another level of care, at time of discharge, and if there is an observed change or deterioration in the patient's condition. Additionally, reassessment occurs on an ongoing basis via daily assessment by a Registered Nurse and Psychiatrist for inpatient treatment...".
b. Under "Procedure", it reads: 1. Reassessment is conducted by a Registered Nurse every 24 hours at a minimum for inpatient treatment and as needed for outpatient services...".

2. Review of patient medical records indicated:
a. Pt. #1 was admitted on 2/11/15, discharged on 2/19/15, and had:
A. A nursing skin assessment by a RN (registered nurse) that indicated "redness" under the right breast and a "rash" on the back of the buttocks and upper thighs (bilaterally).
B. No documentation by the APN (advanced practice nurse) of skin irregularities, as noted by the nurse at the time of admission. In the "Pelvic/genitalia" area, the APN documented "deferred" and in the Breast area, they noted NI (not indicated).
C. Documentation on the "personal effects" form that "antifungal cream" was brought in by the patient on admission. (This cream was never ordered by practitioners.)
D. No further documentation, by nursing staff, of reassessment of the redness and rash noted at the time of admission.
E. No skin reassessment documented at the time of discharge.

b. Pt. #3 was admitted on 2/11/15, discharged on 2/18/15, and had:
A. A nursing skin assessment by a RN that indicated a rash on the back that covered from the left shoulder blade across all of the back to the right shoulder blade.
B. No documentation by the APN of skin irregularities, as noted by the nurse at the time of admission.
C. No further documentation, by nursing staff, of reassessment of the redness and rash noted at the time of admission.
D. No skin reassessment documented at the time of discharge.

3. At 2:10 PM on 3/31/15, interview with staff member #57, a LPN (licensed practical nurse) and nurse manager, indicated:
a. The APNs review the nursing assessment, including the body picture page with notations by nursing staff, prior to conducting their history and physical exams.
b. It is unknown why the APN(s) did not address the redness and rash documented on pt. #1 and the rash documented for pt. #3 in their assessments.
c. There is no documentation in either medical record, pt. #1 and pt. #3, regarding reassessment and follow up, by nursing staff, to the areas noted as red, or rash, present for the adolescents at the time of admission.

4. Review of the policy "Intake Screening and Admissions Process", policy number CTS-009, last revised 3/11, indicated:
a. Under "Procedure", it reads in item 7. on page 6, "...MHT will completes (sic) a "valuables checklist" form listing valuable clothing, keys, purses, eyeglasses, jewelry, money, credit cards, etc..." The policy does not address checking this form at the time of discharge.

5. Review of the form titled "Options Behavioral Health System-Personal Effects" was:
a. Found in the medical records for patients #1, #2, and #3.
b. Completed indicating various personal items and clothing brought to the facility by the patients.
c. Signed by the legal guardian for pt. #1 on a second form (addition of tennis shoes) on 2/14/15, but only with staff signature on the day of admission, 2/11/15 on the first form.
d. Signed by neither parent, patient,or staff for patient #2.
e. Signed only by facility staff for pt. #3.
f. Not completed, for any of the three patients (#1, #2, and #3) in the area at the bottom of the page that reads: "UPON DISCHARGE OR TRANSFER: All of the above items, kept by Options Behavioral Health System until the date below, have been returned to me. I have initialed each item above to indicate the receipt of the items by me and hereby release Options Behavioral Health System from any claim, current or future, of damage, loss or other."
g. Not completed in the boxes for parents, legal guardians, or patients to note a "Date returned", "Pt. initial", and "Staff initial" for each item listed on the form, for any of the three patients, #1, #2, and #3.