HospitalInspections.org

Based on review of the Quality Assurance and Performance Improvement (QAPI) plan and an interview it was determined the hospital failed to assure all hospital services provided participated in QAPI. This affected the dietary services and had the potential to affect all patients served.Findings include:On 6/25/15 at 8:45 AM the hospital QAPI data was reviewed with Employee Identifier (EI) # 1, Director of Performance Improvement. During the review of the data there was no information related to the contracted dietary services which provides all dietary needs for the hospital patients. EI # 1 was asked if the hospital had any QAPI data for dietary and he/she stated he/she would ask.On 6/25/15 at 9:50 AM, Employee Identifier # 3,Infection Control Officer, confirmed dietary does not report QAPI data outside of the environment of care rounds.

Based on the facility Emergency Cart Inventory and Checklist documentation review and interview, it was determined the facility failed to document inspection of the Emergency cart and equipment as per the Emergency Cart Inventory and Checklist written instructions. This had the potential to negatively affect all patients served by the facility.

During a tour of the facility medication room on 6/23/15 at 9:20 AM, the Emergency Cart Inventory and Checklist documentation was reviewed and revealed the Emergency Cart and Automated External Defibrillator (AED) inspections were not performed and documented at the change of each shift on the following dates:

January 2015, 7 AM shift:
1/2/15, 1/7/15, 1/10/15, 1/11/15, 1/15/15 1/20/15, 1/23/15, 1/24/15, 1/25/15

January 2015, 7 PM shift
1/7/15

February 2015, 7 AM shift:
2/3/15, 2/20/15, 2/21/15, 2/26/15 and 2/27/15

March 2015, 7 AM shift
3/2/15, 3/5/15, 3/6/15, 3/7/15, 3/8/15, 3/9/15, 3/10/15, 3/17/15, 3/27/15 and 3/31/15

March 2015, 7 PM shift
3/7/15, 3/8/15, 3/9/15, 3/18/15, 3/26/15 3/27/15, 3/28/15

April 2015, 7 AM shift
4/29/15 and 4/30/15

April 2015, 7 PM shift
4/9/15 and 4/23/15

May 2015, 7 PM shift
5/8/15, 5/21/15, 5/28/15

In an interview on 6/23/15 at 9:25 PM, Employee Identifier # 2, Director of Nursing, confirmed staff failed to perform and document inspection of the Emergency Cart and AED according to facility policy.

Based on record review, facility policies and procedures and interviews, the hospital failed to document:

a) patient's response to as needed medications administered

b) the anatomical location of medication injection sites

c) monitoring of a patient in Time Out

d) an incident report per facility policy

This did affect Medical Records (MR) # 7, # 12, # 14, # 9, # 13, # 8 and # 10, 7 of 10 inpatient records reviewed and had the potential to affect all patients served.Findings include:

Policy: # CTS 4.1
Subject: Use of Room Restriction/Time Out
Revised: 01/15

Procedure:

"Room Restriction and Time Out should be used to assist consumers in regaining self control...

1. Time Out

"...Time Out may take place away from the area of activity or from other consumers...(exclusion area) or in the area of activity...(inclusion area).

Staff must monitor the consumer while...in time out. Documentation on the Time- out Progress Note...support that these procedures are followed and...include the following:

The circumstances that lead to the use of time out regardless of whether...consumer requested, staff suggested, or staff directed.
Name and credentials of staff who monitored the consumer throughout the timeout.
Where on the provider's premises either an inclusionary or exclusionary timeout was implemented.
The length of time for which timeout was implemented
Behavioral or other criteria for release from time out...
The status of the consumer when timeout ended..."


Policy: # CTS 5.0.5
Subject: Charting
Revised: 03/14

Procedure:

"3. Staff will document pertinent, factual information, assessments regarding consumer care, progress...Documentation will reflect the overall treatment plan...actions implemented, consumer's response and any revisions made...
6. A nurse will document all PRN (as needed) medication given and the consumer's response..."


Policy: # HS 1.1/PI 1.9
Subject: Incident Reporting
Revised: 04/15


Policy:

"...provides a method of documentation and tracking of Incidents, Accidents, or Events...out of the ordinary routine of...business activities.

Definition:

Incident/Accident/Event-any occurrence that causes, or may cause harm to, consumers, employees/agents, visitors or property.

Procedure:

1. When an incident happens or is identified, the staff member who has first hand knowledge of the event...shall notify...program coordinator and submit and electronic incident report...
7. The incident Report is transmitted to the file manager...who...will submit the report within 72 hours to the Risk Management Specialist in the Performance Improvement department.
16. Reports are statistically tabulated monthly and...communicated to the Board of Directors..."
1.Medical Record (MR) # 7 was admitted to the hospital on 6/12/15 with a diagnosis of mood disorder. Admission orders included Acetaminophen 325 milligrams (mg), oral tablet, every 4 to 6 hours as needed and Benadryl injection 25 mg to 50 mg two times a day as needed for signs of Extrapyramidal Symptoms (EPS) or Benadryl injection 25 to 50 mg at bedtime as needed for insomnia or Benadryl 12.5 mg to 25 mg capsule every 4 to 6 hours as needed for acute agitation. A review of the Medication Administration Record (MAR) Benadryl, 50 mg injection was administered on 6/12/15 at 8:54 PM for insomnia. There was no documentation by the Registered Nurse about MR #7 ' s response to the as needed medication or the anatomical injection site where the medication was injected.A review of the Medication Administration Record revealed Acetaminophen 325 mg was administered by a Registered Nurse on 6/13/15 at 11:50 AM. There was no reason documented why the as needed medication was administered or MR # 7 ' s response to the medication. A review of the MAR revealed Benadryl 25 mg to 50 mg was administered by a Registered Nurse on the following dates and times with no documentation as to how MR # 7 responded:6/13/15 at 9:12 PM, 50 mg was administered for insomnia.6/14/15 at 3:09 PM, 25 mg was administered for acute agitation.6/21/15 at 9:00 PM, 25 mg was administered for insomnia.6/22/15 at 9:08 PM, 50 mg was administered for insomnia.6/23/15 at 10:39 AM, 25 mg was administered for acute agitation.A review of the MAR revealed Benadryl, 50 mg injection was administered on 6/20/15 at 9:34 PM for aggression/agitation. There was no documentation by the Registered Nurse about MR # 7 ' s response to the as needed medication or the anatomical injection site where the medication was injected. In response to written questions, Employee Identifier (EI) #1, Director of Performance Improvement, confirmed the staff failed to document the anatomical location of the injection sites.



2. Medical Record # 12 was admitted to the hospital on 6/12/15 with a diagnosis of Oppositional Defiant Disorder. A review of the individual progress note dated 6/19/15 documented MR # 12 and another patient was in a physical altercation in the cafeteria. On 6/24/15 EI #1, Director of Performance Improvement, was asked for a copy of the incident report. On 6/24/15 at 4:50 PM, EI #1, Director of Performance Improvement,informed the surveyor there was no incident report completed for the physical altercation that occurred in the cafeteria on 6/19/15.

3. MR # 14 was reviewed for an episode of restraint. On 2/05/15 at 1:43 PM a physician ' s order for restraint due to imminent threat to others and assault on staff was documented in the electronic medical record. The start time of the restraint order was 1:43 PM with an end time of 2:42 PM. A copy of the Hospital Seclusion/Restraint Placement Form was requested.In response to written questions on 6/24/15, EI # 3, Infection Control Officer, provided a written response there was no seclusion/restraint form for 2/05/15.


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4. MR # 9 was admitted to the facility on 6/12/15 with an admitting diagnosis of Psychotic Disorder.

Review of the admission orders revealed orders for Ativan 2 mg (milligrams) injection every 6 hours as needed for severe agitation/aggression, Benadryl 50 mg capsule every 6 hours as needed for Extrapyramidal (EPS) symptoms or stiffness, Acetaminophen 325 mg tablet, 650 mg every 4 to 6 hours as needed for headache, Ativan 2 mg tablet every 6 hours as needed for severe agitation/aggression, Benadryl 50 mg injection for agitation/aggression every 6 hours as needed, Haldol 5 mg injection every 6 hours as needed for psychotic agitation/aggression, Haldol 5 mg tablet every 6 hours as needed for psychotic agitation/aggression and Ibuprofen 200 mg tablet 400 to 600 mg every 8 hours as needed for pain.

Review of the MAR revealed Ativan 2 mg injection was given on 6/12/15 at 8:54 PM and 6/13/15 at 1:58 PM. Review of the MAR revealed the RN (Registered Nurse) failed to document the injection site and the consumer's response from the medication.

Review of the MAR revealed Ativan 2 mg tablet given on 6/18/15 at 9:32 AM and the RN failed to document the consumer's response after receiving the medication.

Review of the MAR revealed Benadryl 50 mg injection was given on 6/12/15 at 8:54 PM, 6/13/15 at 2:00 PM and 6/22/15 at 1:35 PM. Review of the MAR revealed no documentation by the RN of the injection site used or the consumer's response to the medication after it was given.

Review of the MAR revealed Benadryl 50 mg capsule was given on 6/15/15 at 9:16 AM, 6/19/15 at 11:47 AM and 6/19/15 at 3:37 PM. Further review of the MAR revealed the RN failed to document the consumer's response after taking the medication.

Review of the MAR revealed Haldol 5 mg injection every 6 hours as needed was given on 6/12/15 at 8:55 PM, 6/13/15 at 1:59 PM and 6/22/15 at 1:36 PM. Further review revealed the RN failed to document the consumer's response after receiving the injection.

Review of the MAR revealed Haldol 5 mg tablet was given on 6/15/15 at 9:17 AM and 6/19/15 at 3:37 PM. Further review revealed the RN failed to document the consumer's response after receiving the medication.

Review of the MAR revealed Ibuprofen 200 mg tablet 400 to 600 mg every 8 hours as needed was given on 6/17/15 at 10:10 AM, 6/19/15 at 6:14 PM, 6/20/15 at 5:59 AM and 6/21/15 at 11:47 AM. Further review revealed the RN failed to document the consumer's response to the medication and how much medication was given.

An interview conducted on 6/24/15 at 2:30 PM with EI # 1, Director of Performance Improvement confirmed the above mentioned findings.

5. MR # 13 was admitted to the facility on 6/22/15 with an admitting diagnosis of Mood Disorder Not Otherwise Specified.

Review of the admission orders include an order for Benadryl 25 mg capsule give 50 mg at bedtime as needed.

Review of the MAR revealed on 6/23/15 Benadryl 50 mg was given at 9:02 PM by the RN. Further review revealed the RN failed to document the consumer's response after taking the medication.

An interview conducted on 6/24/15 at 3:50 PM with EI #1, Director of Performance Improvement, confirmed the above mentioned findings.



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6. MR # 8 was admitted to the hospital on 6/18/15 with a diagnosis of Mood Disorder Not Otherwise Specified. Admission orders included Acetaminophen 325 mg, oral tablet, every 4 to 6 hours as needed.

Review of the MAR included Acetaminophen 325 mg oral tablet was administered 6/22/15 at 8:57 PM by the RN for complaints of a headache, pain 6 (pain scale-0, no pain, 10, worst pain), continue to monitor.

Record review revealed no documentation the RN monitored and documented MR # 8's response to the as needed medication.

Response to written questions submitted 6/24/15 at 12:00 PM to facility management were received 6/25/15 at 8:00 AM. EI # 1 confirmed staff failed to document therapeutic response to as needed medication.


7. MR # 10 was admitted to the facility on 5/18/15 with diagnoses including Mood Disorder, Not Otherwise Specified, Major Depressive Disorder, severe.

Admission orders included Benadryl 50 mg/1 ml injectable solution, 25 to 50 mg every 4 to 6 hours as needed for acute agitation, Benadryl 25-50 mg oral capsule every 4-6 hours as needed for acute agitation and Acetaminophen 325 mg oral tablet, 650 mg every 4 to 6 hours as needed for pain.

Review of the MAR and the 5/21/15 Nursing Progress Note documentation revealed Benadryl 50 mg oral was administered by the RN for complaints of agitation/restlessness at 9:39 AM. There was no documentation by the RN of the therapeutic response to the as needed medication.

Review of the MAR and 5/26/15 Nursing Progress Note narrative documentation revealed Acetaminophen 650 mg oral was administered by the RN for complaints of headache, 7 of 10 on the pain scale and inability to sleep, Benadryl 50 mg oral at 9:00 PM. There was no documentation by the RN of the therapeutic response to the as needed medications.

Review of the MAR, the 6/2/15 9:41 AM and 6/3/15 9:58 AM Nursing progress Note documentation revealed the consumer was medicated with Benadryl 50 mg oral for complaints of agitation and nervousness. There was no RN documentation for MR # 10's response to the as needed medication.
Review of the MAR revealed Benadryl, 50 mg injection administered on 6/8/15 at 8:02 PM and 6/12/15 at 8:12 PM. There was no documentation by the RN to reveal the anatomical injection site for the medication.

Review of 6/15/15 Group and Individual Progress Notes revealed the following:

At 8:30 AM-10:30 AM, consumer present at enrichment class, uncooperative and disruptive.
11:30 AM-Did not attend Group, see Nursing Note
1:30 PM-1:45 PM (Individual Progress Note)-Therapist met with consumer during anger outburst, Crisis Intervention was offered. Observed consumer cursing at staff, being verbally aggressive towards staff. Consumer (MR # 10) did go to Time Out today for defiant and destructive behaviors.

Review of the 6/15/15 Nursing Progress Note documentation did not reveal MR # 10 was verbally aggressive and required a time out. There was no Time Out Progress Note in the record documentation provided.

The facility failed to follow its own policy for consumer monitoring and documentation during a Time Out.

Review of the 6/23/15 9:34 AM Group and Individual Progress Note documentation revealed the consumer is currently on a therapeutic leave of absence, left yesterday for a pre-placement visit.

Further review revealed a 6/23/15 11:30 AM to 11:50 AM Group and Individual Progress note in which documentation revealed the consumer actively participated in the Focus Group.

The 6/23/15 facility documentation did not represent factual information and assessments regarding the consumers care. MR # 10 was not at the facility to actively participate in the Focus Group.

On 6/25/15 at 8:00 AM written questions from MR # 10's review were submitted to EI # 1, Director of Performance Improvement. Written responses, received on 6/26/15 at 9:00 AM by EI # 4, Performance Improvement Officer and EI # 3, Infection Control, confirmed the aforementioned findings.

Based on review of medical records (MR), facility policies and procedures and interviews, it was determined the facility failed to ensure:

a) Nutritional assessments were performed and documented per policy.

b) All special diets ordered were included in the facility diet manual.

c) Dietary consults were performed and documented per policy.

This did affect MR # 8 and # 10, 2 of 2 records reviewed with special diet orders and a change in the nutritional status. This had the potential to negatively affect all patients treated in this facility.

Findings include:

Policy # CTS 5.0
Subject: Special Diets
Revised 12/14

"Policy:

To ensure...the needs of the individual with special nutritional requirements are met as prescribed by the physician/CRNP (Certified Registered Nurse Practitioner)...

Procedure:

1. The nurse, at admission will assess the nutritional needs of the consumer and review orders for special diets. If a nutritional consult is indicated, the nurse will notify the dietician. If a special diet is indicated, the physician/CRNP will write an order.

4. In inpatient programs...
The dietician documents recommendations in the consumer record. The program nurse notifies the MD (medical doctor)/CRNP of recommendations..."

Policy # PE 1.2
Subject: Assessment for Treatment
Revised 12/14

"Policy:

Assessment is initiated during the intake/admission process; however, assessment is not limited to the admission period. Factors included in assessment are social, medical, psychological...and developmental issues....

Procedure:

2. Nursing assessment/Medical Checklist

...The need for further physical health assessment is determined based on the following criteria:
...Review of general health systems that include abnormal findings (i.e. nutrition, cardiovascular...and/or central nervous system)

3...An expanded nutritional assessment requiring a dietary consult may be triggered by one or a combination of any of the following...
High Risk
...Anorexic/Purging...
Medium Risk
...Nausea/Vomiting
Constipation..."


1. MR # 8 was admitted to the facility on 6/18/15 with diagnoses including Mood Disorder Not Otherwise Specified.

Record review revealed a 6/18/15 1:26 PM physician's order for a Low Sodium diet.

Review of the medical record documentation failed to reveal a dietary consult was requested and performed for a patient with a special diet order. There was no documentation of the dietician's recommendations to meet MR # 8's special nutritional requirements.

Review of the 6/12/15 Baypointe Hospital Diet Manual documentation, failed to include a diet plan for a Low Sodium diet.

In an interview on 6/26/15 at 8:25 AM, Employee Identifier (EI) #1, Director of Performance Improvement, confirmed the above findings.

2. MR # 10 was admitted to the facility on 5/18/15 with diagnoses including Mood Disorder, Not Otherwise Specified, Major Depressive Disorder, severe.

Review of the 5/18/15 Nursing Admission Assessment included "Assessed needs for Nutritional/Special Diets...from consumer...Appetite: Good, Eats regular balanced meals: Yes, Purging: No...Nutritional Assessment complete..."

Record review revealed a 5/18/15 8:03 PM physician's order for a Regular diet.

Review of the 5/19/15 Psychiatric Evaluation documentation revealed MR # 10's "nutritional status appears good" and a Regular diet was ordered. There was no documentation to reveal a history of nutritional abnormalities.

Review of the 5/20/15 Nursing Progress Note documentation at 7:47 AM included the following: "...Gastrointestinal: Nausea, WNL...Elimination: Constipation...Narrative Notes...Consumer reports nausea with eating...Nursing Assessment complete. At 3:05 PM, consumer reports lower right quadrant pain...will continue to monitor".

Record review revealed a 5/20/15 10:38 AM physician's order for 30 minute observation after meals and instructed no use of bathroom directly after meals (purging).

Review of the 5/20/15 and 5/21/15 nursing progress note documentation failed to reveal a reassessment of MR # 10's nutritional status was performed following reports of purging.

Review of the 5/21/15 8:00 AM -8:17 AM Group and Individual Progress Note documentation revealed the following: "...states that...purged yesterday morning after breakfast and lunch...this was shared with staff..."

Review of the 5/21/15 Nursing Progress Note documentation included Observations: meal observation and Gastrointestinal: WNL (within normal limits).

Review of the 5/22/15 9:00 AM -9:15 AM Group and Individual Progress Note documentation revealed MR # 10 remains on observation due to bulimia protocols.

Review of physician's orders dated 6/19/15 included a request for a lactose intolerant diet, avoiding milk, yogurt and ice cream and providing alternate options for meals and snacks.

Review of the nursing documentation failed to reveal MR # 10's nutritional needs were reassessed after the purging (abnormal nutritional finding), bulimia protocol implemented and special (lactose intolerant) diet need identified.

There were no nutritional reassessments documented, dietary consults completed or performed for MR # 10.

In an interview on 6/25/15 at 8:25 AM with EI #1, Director of Performance Improvement, the above findings were confirmed.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served.

Findings include:

Refer to Life Safety Code violations.

Based on medical record (MR) review and interviews, the facility failed to ensure individual therapy was provided as ordered. This affected MR's # 10, # 8 and # 11, 3 of 8 active records reviewed. This had the potential to negatively affect all patients treated at the facility.

Findings include:

1. MR # 10 was admitted to the facility on 5/18/15 with diagnoses including Mood Disorder, Not Otherwise Specified, Major Depressive Disorder, severe.

Review of the 5/20/15 Hospital Treatment Plan revealed ordered treatment modalities included individual therapy 1 time per day, person responsible named Medical Social Worker (MSW).

MR review failed to include documentation individual therapy was performed on the following days: 5/25/15, 5/30/15, 5/31/15, 6/7/15, 6/13/15, 6/14/15, 6/20/15 and 6/21/15.

The facility was given a written list of questions on 6/25/15 at 8:00 AM concerning MR # 10. On 6/26/15 at 9:00 AM the facility provided the list of questions back with written responses. The written response from hospital staff confirmed the facility failed to provide and document daily individual therapy for MR # 10 as ordered.


2. MR # 8 was admitted to the facility on 6/18/15 with diagnoses including Mood Disorder Not Otherwise Specified.

Review of the 6/19/15 Physician Psychiatric Evaluation documentation revealed plans for patient participation in individual therapy.

Review of the medical record revealed no documentation the patient participated in individual therapy on 6/19/15, 6/20/15 and 6/21/15.

The facility was given a written list of questions on 6/24/15 at 12:00 PM concerning MR # 8. On 6/25/15 at 9:00 AM the facility provided the list of questions back with written responses. The written response from the hospital staff confirmed the facility failed to provide and document daily individual therapy for MR # 8.


3. MR # 11 was admitted to the facility on 6/17/15 with diagnoses including Mood Disorder Not Otherwise Specified, Anxiety Disorder and Suicide Attempt.

Review of the 6/18/15 Hospital Treatment Plan revealed ordered treatment modalities that included individual therapy 1 time per day, person responsible named MSW.

Review of the medical record revealed no documentation individual therapy was performed daily as ordered on 6/21/15.

The facility was given a written list of questions on 6/24/15 at 12:00 PM concerning MR # 11. On 6/25/15 at 9:00 AM the facility provided the list of questions back with written responses. The written response from the hospital staff confirmed the facility failed to provide and document individual therapy daily for MR # 11.

Based on review of medical records (MR), review of policy and procedures and interview, it was determined in 1 of 1 open records with stays greater than 30 days reviewed the treatment team failed to update or change the goals, both short term and long term, and failed to update the interventions to meet the goals in the acute care setting. This affected MR # 10 and had the potential to affect all patients served by this facility.

Findings include:

Policy #: CTS 1.2
Subject: Treatment, Treatment Plan and Review
Revised: 02/15

Policy:

"In order to ensure the appropriateness of care, treatment plans and reviews will be conducted...All treatment plans and reviews will meet expect standards of ...other governing bodies.

...services must be individualized, well-planned, and should include treatment designed to enhance the consumer's ability to recover...

Procedure:

2. The treatment plan will include clinical issues...and the services to address those issues...The treatment plan will state the expected outcomes for each goal.
3. Treatment plans should include referrals for services not provided directly by AltaPointe...
6...Consumer preferences and opinions about treatment, care services...objectives will be documented on the treatment plan.
10. Treatment plans will be reviewed and updated for Medicaid enrollees...
on a monthly basis..."


MR # 10 was admitted to the facility on 5/18/15 with diagnoses including
Mood Disorder, Not Otherwise Specified, Major Depressive Disorder, severe, admitted after an attempted suicide by drug overdose and exhibiting severe depression.

Review of the Hospital Treatment Plan dated 5/19/15 included the following documentation:

Master Problems

Axis-I
Date Identified: 5/18/15

Problem: Risk for Suicide as evidence verbalizes thoughts/plans to end life.
Short Term Goal/Objective-Consumer will be safe and free from injury- Date formulated 5/18/15; Target Date: 5/25/15, Status: Active
Interventions with Focus: The nurse will administer medications as ordered to promote stabilization.

Master Problems

Axis-I

Date Identified: 5/19/15

Problem: MR #10 is experiencing depression and suicidal ideation.

Short Term Objective: Explore, develop and utilize positive coping skills 5 of 7 days per week to better manage anger and decrease and/or eliminate suicidal ideation, state identified coping skills used during family and individual sessions.

Date Formulated: 5/19/15; Target Date: 6/2/15, Status: Active

Intervention with Focus:

Individual and Family Therapy to decrease/eliminate suicidal ideation,address anger and aggression; Recreational and Group therapy to address peer interaction, Psychiatric rounds to address symptoms/medication adjustment and monitoring

Criteria for Discharge (long term goal):
Consumer (MR # 10) will have a decrease or elimination in suicidal ideations.
Consumer strengths/assets which facilitate achievement of goals: Motivated for treatment
Liabilities/weakness and special needs-possible treatment barriers:
Educational concerns
Family Participation: Release obtained-family participation.

Master Problems

Axis-III
Date Identified: 5/21/15, Status: Active
Problem: Risk for Constipation as evidenced by: Consumer reports several days between normal bowel movements
Short Term Goal/Objective: Consumer will have a bowel movement every 2-3 days
Date Formulated: 5/21/15; Target Date: 5/24/15
Intervention with Focus: The nurse will administer ordered medications to relieve constipation and help to provide a well balance diet high in fiber.


Review of the Updated Hospital Treatment Plan dated 6/19/15 revealed the following documentation:

Master Problems

Axis-I

Date Identified: 5/18/15, Status: Active

Problem: Risk for Suicide as evidenced by: Consumer Verbalizes thoughts/plans to end life.

Short Term Goal/objective: Consumer will be safe from Injury
Date Formulated: 5/18/15; Target Date: 5/25/15, Status: Active
Intervention with Focus: The nurse will administer medications as ordered to promote stabilization.

Master Problems

Axis-I

Date identified: 6/19/15; Status: Active

Problem: Consumer is experiencing depression and suicidal ideation as evidenced by: reports attempted overdose and having thoughts of wanted to drown in the bathroom this morning.

Short Term Goal/Objective: Consumer will explore, develop and utilize positive coping skills 5 of 7 days per week to better manage anger and decrease and/or eliminate suicidal ideation. State identified coping skills during both family/individual sessions.

Date Formulated: 6/19/15; Target Date: 7/3/15; Status: Active
Intervention with Focus: Individual and Family Therapy to decrease/eliminate suicidal ideation, address anger and aggression; Recreational and Group therapy to address peer interaction, Psychiatric rounds to address symptoms/medication adjustment and monitoring

Master Problems

Axis-III

Date Identified: 5/21/15, Status: Active
Problem: Risk for Constipation as evidenced by: Consumer reports several days between normal bowel movements
Short Term Goal/Objective: Consumer will have a bowel movement every 2-3 days
Date Formulated: 5/21/15; Target Date: 5/24/15
Intervention with Focus: The nurse will administer ordered medications to relieve constipation and help to provide a well balance diet high in fiber.

Review of the 6/19/15 Updated Hospital Treatment Plan failed to include revised short and long term goals.

Medical record review of the Medication Administration Record, Individual Therapy progress notes and physician orders revealed the following:

a) Consumer reported "purging"; 30 minute observation after meals/no use of bathroom directly after meals with bulimia protocol interventions initiated on 5/20/15

b) Multiple use of prn's (as needed) medications to manage agitation between 5/22/15 and 6/15/15

c) Became a ward of the state, Department of Human Resources granted custody on 5/26/15

d) Placed on suicide watch 1:1 observation 6/1/15 to 6/4/15 after verbalizing suicidal ideation

e) Suicide ideations observed during Group therapy on 6/10/15-consumer drew a picture of a gun

f) Verbally aggressive towards staff, placed in Time Out on 6/15/15

g) On 6/18/15 awaiting pre-arranged therapeutic visit for potential foster placement through Alabama Mentor

The facility was given a written list of questions on 6/25/15 at 8:00 AM concerning MR # 10. On 6/26/15 at 9:00 AM the facility provided the list of questions back with written responses. The written response from hospital staff, Employee Identifer # 3, Infection Control Office confirmed the facility failed to revise and update the treatment plan including short and long term goals and interventions to meet MR # 10's mental and physical needs.