HospitalInspections.org

Based on policy review, record review and staff interview, the facility failed to provide 10 (#8, #11, #12, #13, #14, #16, #17, #18, #19 and #20) of 20 sampled patients with the Important Message from Medicare Letter upon discharge. This practice does not ensure patients are informed of their rights.

Findings include:

During the closed electronic medical record reviews that were conducted on 2/5/13 at approximately 3:00 p.m. revealed the facility did not include the Important Message Letter from Medicare (IM) as part of the patient medical record for patients #8, #11, #12, #13, #14, #16, #17, #18, #19 and #20.

An interview was conducted with the Vice President of Administrative Services on 2/5/13 at approximately 3:30 p.m. in regards to the location of the letter to the patients. She stated the letter was located in the financial record of the patient and not in the medical record. She would contact the finance department and have them fax over the documentation.

On 2/6/13 at approximately 9:00 a.m. the Director of Administration provided copies of the first Important Message Letter from Medicare that was issued to the above patients upon admission. However, upon review of the documentation that was provided, it was noted the patients were not being provided with the second delivery of the standardized IM as required at discharge.

An additional interview with the Vice President of Administrative Services was conducted on 2/6/13 at approximately 9:00 a.m. in which she confirmed that the second required letter was not being provided to the patient.

Policy #I.A7.20.1 for Financial Intake Procedures #6 reads: Have client read and sign Medicare Rights Form (Attachment G). No further explanation was provided.

Based on medical record review and staff interview it was determined the facility failed to ensure a registered nurse assessed, implemented interventions and evaluated the nursing care related to skin care needs identified upon admission for one (#8) of twenty patients sampled. This practice does not ensure patient needs and goals are met.

Findings include:

Patient #8's admission note by the RN (Registered Nurse) on 1/17/2013 at 6:45 p.m. stated the patient had a decubitus ulcer on the coccyx. Review of the record revealed no documentation of size or stage of the ulcer, surrounding skin appearance, physician notification or treatment until 1/22/2013. Documentation revealed the patient needed assistance with ambulation, grooming, bathing and toileting.

On 1/22/2013 at 4:16 a.m. the RN documented the technician informed the nurse of a decubitus ulcer located on the patient's lower right buttock. The RN assessed and noted the right buttock with a decubitus the size of a silver dollar with a soggy, serous stained dressing loosely attached that appeared to be on since the patient's admission on 1/17/2013. The RN noted the left buttock with noticeable skin break down of a corresponding size. The physician was informed, orders received and treatment provided.

Interview with the Director of Nursing on 2/5/2013 at 2:30 p.m. confirmed the above findings.

Based on medical record review and staff interview it was determined the facility failed to ensure the nursing staff developed a nursing care plan for skin care needs identified on admission for one (#8) of twenty patients sampled. This practice does not ensure patient's identified needs are met.

Findings include:

Patient #8's admission note by the RN (Registered Nurse) on 1/17/2013 at 6:45 p.m. stated the patient had a decubitus ulcer on the coccyx. Review of the patient's plan of care implemented on 1/17/2013 revealed no evidence of identification of the problem for the ulcer, no goals, or interventions.

On 1/22/2013 the problem of the decubitus ulcer was identified on the plan of care. Goals with target dates, interventions and responsible staff was implemented. Nursing failed to implement a plan of care for the patient's decubitus ulcer upon admission on 1/17/2013.

Interview with the Director of Nursing on 2/5/2013 at 2:30 p.m. confirmed the above findings.

Based on observation in the main kitchen and staff interview it was determined the facility failed to ensure that equipment and techniques for food sanitation were maintained to ensure a sanitary environment. This practice places patients and staff at risk for food borne illness and physical contamination.

Findings include:

During the tour of the main kitchen on 2/4/2013 beginning at 11:20 a.m. with the Dietary Manager the following was noted:

1. Review of the log for food temperatures monitored at each meal revealed no documentation of temperature for dinner on 2/3/2013 and breakfast on 2/4/2013.

Interview with the cook, staff member #3, revealed the temperatures were taken but he was unable to provide accurate documentation of same. Interview with the Dietary Manager revealed the temperatures should be tested and logged at each meal.

2. Observation of the 3 compartment sink revealed items in the process of cleaning and sanitation. The Dietary Manager was observed to test the level of sanitizer. The result revealed 0 ppm (parts per million) indicating no presence of sanitizer.

3. Observation of the food server, staff member #5, testing food temperatures on the food line was completed at 12:00 p.m. The server retrieved the thermometer and proceeded to place the stem in the soup. While testing the temperature of the soup the server dropped the thermometer into the soup. With an unsanitized and ungloved hand the server retrieved the thermometer from the soup.

Interview with the server revealed he did not sanitize the thermometer prior to placing the stem in the soup. He confirmed he was unaware if the thermometer was sanitized prior to use.

Based upon record reviews and interviews, it was determined that in 8 of 8 patient records (A1, A2, A3, A4, A5, A6, A7 and A8) the hospital failed to assure the reporting of memory and orientation findings as part of the Psychiatric Evaluation. This compromises the database from which diagnoses are made and treatment determined.

Findings Include:

A. Record Review

1. Patient A1: Patient admitted 1/25/13. Psychiatric Evaluation Mental Status Exam (MSE) dated 1/26/13 fails to report memory and orientation findings.

2. Patient A2: Patient admitted 1/31/13. Psychiatric Evaluation (MSE) dated 2/1/13 fails to report memory and orientation findings.

3. Patient A3. Patient admitted 1/28/13. Psychiatric Evaluation (MSE) dated 1/31/13 fails to report memory and orientation findings.

4. Patient A4. Patient admitted 1/31/13. Psychiatric Evaluation (MSE) dated 2/1/13 fails to report memory and orientation findings.

5. Patient A5. Patient admitted 1/18/13. Psychiatric Evaluation (MSE) dated 1/18/13 fails to report memory and orientation findings.

6. Patient A6. Patient admitted 11/18/12. Psychiatric Evaluation (MSE) dated 11/18/12 fails to report memory and orientation findings.

7. Patient A7. Patient admitted 2/2/13. Psychiatric Evaluation (MSE) dated 2/3/13 fails to report memory and orientation findings.

8. Patient A8. Patient admitted 1/31/13 Psychiatric Evaluation (MSE) dated 1/31/13 fails to report memory and orientation findings.


B. Interviews:

1. In an interview on 2/5/13 at approximately 11:30 a.m. the Psychiatric Evaluations were reviewed with the Medical Director. The Medical Director acknowledged the findings.

2. In an interview on 2/5/13 at 1:00 P.M the surveyors presented the above findings to the hospital Director of Nursing. The Director of Nursing acknowledged the findings.

Based on record review, policy review and interview the facility failed to ensure that the Master Treatment Plans (MTP) for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) were developed by a treatment team, and based on the assessments of the various clinical disciplines. According to hospital policy, the nurses start the MTP at the time of admission; they choose from a computerized list of physician and nurse interventions, and before all the assessments are completed. Failure to develop a comprehensive plan can result in patients not receiving the interventions necessary for timely discharge, and successful transition to the community after discharge.

Findings include:

Record Review:

1. Patient A1 was admitted 1/25/13. The MTP was dated 1/25/13 and stated:
"Physician will complete a psychiatric evaluation within 24 hours and prescribe antidepressants as indicated." "APRN/Physician will complete a History and Physical within 24 hrs to address medical concern to prescribe pain medication as indicated, order Lab Studies and evaluate daily as indicated x 7 days." These are assessments.

2. Patient A2 was admitted 1/31/13. The MTP was dated 1/31/13 and stated: "Physician will complete a psychiatric evaluation (an assessment) within 24 hours and prescribe mood stabilizers and lab studies as indicated."

3. Patient A3 was admitted 1/28/13. The MTP was dated 1/30/13 and stated: "ARNP/Physician will complete a Health and Physical with 24 hrs to address cough, nasal congestion (an assessment)...."

4. Patient A4 was admitted 1/31/13. The MTP was dated 1/31/13 and stated: "Physician will complete a psychiatric evaluation within 24 hours (assessment).... ARNP will complete History and Physical with 24 hours to order lab studies if indicated (assessment) and address any ETOH related medical conditions...." "Nursing staff will evaluate [patient] 3 times daily x 7 days for complications of Alcohol withdrawal...."

5. Patient A5 was admitted 1/18/13. The MTP was dated 1/18/13 and stated: "Physician will complete a psychiatric evaluation within 24 hours (assessment)...."

6. Patient A6 was admitted 11/18/12. The updated MTP dated 1/24/13 stated: "Physician will complete a psychiatric evaluation within 24 hours to evaluate mental status (assessment) ...."

7. Patient A7 was admitted 2/2/13. The MTP was dated 2/2/13 and stated: "Physician will complete a psychiatric evaluation within 24 hours (assessment).... ARNP/Physician will complete a History and Physical with 24 hours to address medical concerns related to poly substance use, ordering labs studies as indicated (assessment). Nursing staff will evaluate [patient] 3 times daily x 7 days for withdrawal symptoms..."

8. Patient A8 was admitted 1/31/13. The MTP was dated 1/31/13 and stated: "Physician will complete a psychiatric evaluation within 24 hours (assessment)...."

Policy Review

Policy # 903 dated 6/6/2012, "Treatment Planning." states, "It is the policy of Manatee Glens Hospital to begin the treatment planning process at the time of admission with active patient and family input in addition to participation with continuous review and updating"....

Interview:

During an interview with the Director of Nurses (DON) on 2/5/13 at approximately 1:30 p.m., she stated that the nurse is primarily responsible for developing the MTP at the time of admission.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) that identified physician and nursing interventions that were individualized and specific to the treatment needs for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Instead, the MTPs included interventions from a computer list which were either actually discipline assessments, or were routine, generic discipline functions that lacked focus for treatment. This failure results in treatment plans that do not reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient A1 admitted 1/25/13. The MTP dated 1/25/13 listed the problem/issue as "Depression with suicidal ideation." "[Patient] is admitted involuntarily after making a suicidal statement to [his/her] therapist today." Staff interventions were listed as:

"Physician will complete a psychiatric evaluation within 24 hours and prescribe antidepressants as indicated." "APRN/Physician will complete a History and Physical within 24 hrs to address medical concern to prescribe pain medication as indicated, order Lab Studies and evaluate daily as indicated x 7 days." These are assessments. "Nursing will administer [patient] prescribed medication and evaluate 2 times daily for adverse medication side effects and efficacy using a pain scale x 7 days." These are generic staff functions.

2. Patient A2 admitted 1/31/13. The MTP dated 1/31/13 listed the problem/issue as "Bipolar Disorder/Mania" "[Patient] is currently very manic with flight of ideas, delusional and tangential." Staff interventions were listed as:

"Physician will complete a psychiatric evaluation (an assessment) within 24 hours and prescribe mood stabilizers and lab studies as indicated." "Nursing staff will provide [patient] medication education groups on mood stabilization medication indications for use, side effects and expected therapeutic response daily x7 days." These are generic staff functions.

3. Patient A3 admitted 1/28/13. The MTP dated 1/30/13 listed the primary problem/issue as Alcohol Dependence and a medical issue as Upper Respiratory Infection. Active. Staff interventions were listed as:

"ARNP/Physician will complete a Health and Physical with 24 hrs to address cough, nasal congestion (an assessment) and prescribe antibiotic therapy and lab studies as indicated." "Nursing staff will provide [patient] education related to preventing the spread of infection, good hand washing techniques and hygiene 1x with 7 days of admission." These are generic staff functions.

4. Patient A4 admitted 1/31/13. The MTP dated 1/31/13 listed the problem as Alcohol Dependence and medical issues such as a "history of withdrawal seizures." "[Patient] reported drinking a quart of liquor a day." Staff interventions were listed as:

"Physician will complete a psychiatric evaluation within 24 hours (assessment) and prescribe medications, evaluate, stabilize and medically detox [patient] from alcohol. ARNP will complete History and Physical with 24 hours to order lab studies if indicated (assessment) and address any ETOH related medical conditions including Cirrhosis, Wilson's disease and Esophageal Variances." "Nursing staff will evaluate [patient] 3 times daily x 7 days for complications of Alcohol withdrawal and medicate with PRN as ordered to maintain medical stability." These are generic staff functions.

5. Patient A5 admitted 1/18/13. The MTP dated 1/18/13 listed the primary problem as Depression and suicidal attempt. S/he demonstrated wrist scratches made with a broken TV antenna. Staff interventions were listed as:

"Physician will complete a psychiatric evaluation within 24 hours (assessment) and prescribe antidepressants as indicated." "Nursing will administer [patient] prescribed medication and evaluate 2 times daily for adverse medication side effect and efficacy using a pain scale x 7 days." These are generic staff functions.

6. Patient A6 admitted 11/18/12. The updated MTP dated 1/24/13 listed the problems of Depression with suicidal attempt. "[S/he] describes as feeling hopeless and helpless and not in control of [his/her] life. S/he has a history of 25 prior admissions to this facility." Staff interventions were listed as:

"Physician will complete a psychiatric evaluation within 24 hours to evaluate mental status (assessment) and prescribe antidepressants as indicated. Nursing staff will provide medication education group 4 times per week to provide [patient] information on the prescribed antidepressant medication, side effects and expected therapeutic response daily x7 days." These are generic staff functions.

7. Patient A7 admitted 2/2/13. The MTP dated 2/2/13 listed the primary problem as Poly-Substance Abuse/Dependence. S/he came to this facility; "to get help with my dependence on pain medication." Staff interventions were listed as:

"Physician will complete a psychiatric evaluation within 24 hours (assessment) and prescribe detox medications as indicated - ARNP/Physician will complete a History and Physical with 24 hours to address medical concerns related to poly substance use, ordering labs studies as indicated (assessment). Nursing staff will evaluate [patient] 3 times daily x 7 days for withdrawal symptoms and medicate with PRN medications as needed to control blood pressure and prevent delirium tremors." These are generic staff functions.

8. Patient A8 admitted 1/31/13. The MTP dated 1/31/13 listed the primary problem as Depression with Suicidal Ideation and Poly-Substance abuse. "[Patient] has made multiple suicide attempts in the past and prior to [his/her] admission [his/her] attempt was by walking into traffic a month ago." Staff interventions were listed as:

"Physician will complete a psychiatric evaluation within 24 hours (assessment) and prescribe antidepressants as indicated. Nursing staff will provide medication education groups 4 times per week to provide [patient] information on Antidepressant medication." These are generic staff functions.

B. Interview

During an interview with the Director of Nurses (DON) on 2/5/13 at approximately 1:30 p.m., she acknowledged that the interventions from the physician and nursing on the Master Treatment Plans were generic.