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Based on record review and interview, the hospital failed to ensure the grievance process was implemented as evidenced by failing to identify, investigate, and document a patient's grievance for 1 out of 1(Patient #2) patient's documentation of a grievance reviewed out of a sample of 5.
Findings:

Review of the hospital's policy for Patient Complaints and Grievances revealed in part, III Procedure: A "Patient Grievance" is defined as a formal, written, or verbal allegation or source of dissatisfaction that is filed by a patient or patient's representative that requires and investigation.

Review of Patient #2's medical record revealed he was admitted to the hospital on 7/13/16 by a PEC (Physician Emergency Certificate) for Suicidal ideation with a plan.

An interview was conducted with S4LMSW on 8/9/16 at 10:30 a.m. She reported she was the case manager for Patient #2 while he was hospitalized from 7/13/16 to 7/19/16. She reported she received a phone call from Patient #2 on the evening of his discharge (7/19/16), he reported to her the shelter didn't have a bed for him and he couldn't get one of his medications.

An interview was conducted with S5Risk Manager with 8/9/16 at 1:45 p.m. S5Risk Manager reported she was the person responsible for the grievances and complaints at the hospital. She further reported she was not aware of a grievance called in on the phone by Patient #2 after his discharge and there was no documentation of the grievance and investigation. She also reported the phone call should have been handled as a grievance.

Based on record review and interview, the hospital failed to ensure all direct care staff were competent in the application of restraints as evidenced by failing to ensure competencies for 2 (S7MHT and S8RN) out of 3 direct care staff (S7MHT, S8RN and S9MHT) personnel records reviewed. Findings:

Review of the hospital's policy on Staff Competency, Policy Number HR.012, revealed in part, Purpose to provide a method of evaluating staff's level of competency within an assigned department and job description. III. Procedure Method of assuring staff competency....3. Skills Check List, department, and/or population specific.

Review of the personnel record for S7MHT revealed her date of hire was 5/04/16. With further review of her personnel records revealed no documentation of her being competent in the application or monitoring of restraints.

Review of the personnel record for S8RN revealed her date of hire was 07/06/16. With further review of her personnel record revealed no documentation of her being competent in the application or monitoring of restraints.

An interview was conducted with S2DON on 8/10/16 at 1:00 p.m. She reported she did not have documentation of S7MHT and S8RN skill competencies.

Based on record review and staff interview, the hospital failed to ensure the patient's discharge plan was implemented by the Social Worker in accordance with hospital policy as evidenced by the Social Worker failing to meet with the patient to discuss the planning needs, and failing to send patient information to the post hospital care provider for 1 (#5) of 5 (#1-#5) sampled patients.
Findings:

Review of the hospital policy titled, Discharge Planning Process, Policy #PM 024 revealed in part the following: The therapist is responsible for completing the psychosocial aftercare plan with the patient prior to discharge....The social service staff is responsible for coordinating the discharge plan....Aftercare Plan: Tasks to be accomplished: Finalize arrangements for patient and family to enter continuing care program....

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was discharged on 07/05/16 at 10:50 a.m.
Review of the Discharge Care Plan and Home Medications form revealed an aftercare appointment was made with a mental health clinic. Further review of the Discharge Care Plan revealed the section titled Continuing Care Coordination revealed the section was left blank. This section of the form revealed, "*Must be transmitted within 24 hours of discharge and fax confirmation page must be retained in the medical record. The discharge plan was transmitted and shared with the following providers:" Further review of the Discharge Plan revealed the section titled, "Other Important Contact Information" was left blank. This section included space for documentation of the name and number of a Support Person, Insurance Customer Service, Crisis Team, Support Group for self, Support Group for family, and other resources. The Discharge Plan was signed only by the RN.
Review of the Interdisciplinary Progress Note dated 07/05/16 at 10:50 a.m. revealed the social worker documented the patient's mother confirmed the patient had a home to return to and there were no weapons in the patient's home. There was no documented evidence of any other discharge instructions, planning or coordination with aftercare providers.

In an interview on 08/10/16 at 10:40 am S3Clinical Director reviewed the medical record for Patient #5 and stated, "It looks like social services was not involved in this discharge." S3Clinical Director stated it may have not been done because the social worker was not available when the patient was discharged. After reviewing a calendar, she stated social services were not working the day the patient was discharged. S3Clinical Director stated, "It's not good, but that's the reason." S3Clinical Director stated the aftercare appointment was made prior to the date of discharge and confirmed patient information was not sent to the aftercare provider as required. She confirmed the social worker should have faxed patient information to the provider and documented that in the Continuing Care Coordination section. S3Clinical Director confirmed the Important Contact Information should have been completed by the social worker at the time of discharge. S3Clinical Director stated the social worker should have signed the Discharge Care Plan and Home Medications form on the day of discharge.

26351

Based on record review and interview, the hospital failed to ensure each patient had an individual comprehensive treatment plan as evidenced by:

1. The hospital failed to meet the patients' needs by not addressing all the patients' needs in the treatment plan for 4 (#2, #3, #4, #5) of 5 (1-5) sampled patients;

2. The hospital failed to development and implement the patients' treatment plan within 72 hours per the hospital's policy for 2 (#1, #2) of 5 (#1-#5) sampled patients;

3. The hospital failed to include the patient in the development of the treatment plan of care for 1 (#5) of 5 (#1-#5) sampled patients, and;

4. The hospital failed to ensure the patient's Treatment Plan included individualized, measurable goals and interventions for identified problems for 2 (#1, #3) of 5 (#1-#5) sampled patients.

Findings:

1. Not addressing all the patients' needs in the treatment plan:

Review of the hospital policy titled, Interdisciplinary Treatment Planning - Overview, Policy # NU 453 revealed in part the following:
It is the policy that each patient admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments ....Any psychiatric and/or active medical problems that occur throughout their stay must be included in the interdisciplinary treatment plan.
Master problem list is initiated by the admitting nurse upon admission. The list is based on the intake information, the medical/psychiatric history and physical, the nursing assessment and the patient/family information, as well as any other assessments completed.
Problem Sheet: ....Short-term objectives are then listed. These must be specific, measurable, and represent a patient's steps toward reaching the long-term goal. A target date should be indicated as well as a date objectives are met or revised. Interventions are completed by each discipline and should include the specific plan of intervention as well as frequency. Each discipline should indicate the name of the person responsible and the date the intervention is implemented and/or revised ....


Patient #2
Review of Patient #2 medical record revealed he was admitted to the hospital on 7/13/16 for Major Depression recurrent severe with Psychotic Features and Polysubstance Abuse. Review of the admission lab work revealed he was positive for Cocaine and review of the PEC (Physician's Emergency Certification) dated 7/13/16 revealed he had a suicide plan to commit suicide by overdosing on heroin.

Review of the patient's treatment plan revealed the Therapy Master Problem List included 1 problem: Alteration in Mood: Depression. With review of the treatment plan revealed his Polysubstance abuse problem was not addressed.

An interview was conducted with S3Clinical Director on 8/09/16 at 9:54 a.m. With review of Patient #2's treatment plan, she reported his substance abuse problems should have been addressed in the treatment plan and they were not addressed.


Patient #3
Review of the medical record for Patient #3 the patient was a 32 year old admitted to the hospital on 07/26/16 with a diagnosis of Bipolar Disorder, Depression. The record revealed the patient was a Formal Voluntary Admit from a group home.
Review of the Psychosocial Assessment revealed the reason for admission was, "Acting up" at the group home. The assessment revealed the patient was off his medications due to his Medicaid being stopped and he could not afford the medications.

Review of the patient's Treatment Plan revealed the patient's strengths were identified as Access to Resources, Good physical Health, and Good Hygiene. Review of the Therapy Master Problem List revealed the only problem identified was, "Alteration in mood - depressed." There was no documented evidence that the patient's problem of obtaining his medications was identified as a problem in the Treatment Plan. Further review of the Treatment Plan revealed the only intervention identified for the problem of Alteration in mood, was, "Help patient cope with depression."

In an interview on 08/09/16 at 2:30 p.m. S10LMSW reviewed the patient's medical record and Treatment Plan and confirmed the patient's inability to get medications led to his hospitalization here and that should have been included in his treatment plan, but it was not.


Patient #4
Review of Patient #4's medical record revealed she was admitted to the hospital on 6/2/16 for Bipolar, Depression Severe with Psychotic Features with Suicidal Ideation, Marijuana and Possible Cocaine Abuse. Review of the Psychiatric Evaluation dated 6/03/16 revealed the patient had a positive drug screen for Cocaine on admission to the hospital.

Review of Patient #4's Treatment Plan revealed on the Therapy Master Problem List on only Problem listed was Depression. With review of the treatment plan revealed the patient's Polysubstance abuse was not addressed.

An interview was conducted with S3Clinical Director on 8/09/16 at 3:10 p.m. With review of Patient #4's treatment plan, she reported her substance abuse problems should had been addressed in the treatment plan and they were not addressed.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was admitted under a PEC dated 06/29/16 for being dangerous to self and others, and unable to seek voluntary admission. Review of the physician orders dated 06/30/15 revealed Alcohol Detox standing orders were prescribed.

Review of the Treatment Plan revealed no documented evidence of any Therapy problems identified for the patient. There were no identified problems related to the patient's psychiatric diagnoses or Poly-Substance abuse, and there was no documented evidence that the alcohol detox was included in the written Treatment Plan.

In an interview on 08/10/16 at 10:40 a.m., S3Clinical Director reviewed the Treatment Plan for this patient and confirmed there were no therapy problems identified in the Treatment Plan and the Alcohol Detox was not included in the Treatment Plan. S3Clinical Director confirmed the Therapy problems were the responsibility of social services, and the Treatment Plan was not done by the social worker. S3Clinical Director stated during this time the staff was reduced to 2 social workers and they were short staffed.



2. Treatment plan not done within 72 hours:

Review of the Hospital policy, Policy Number NU453, revealed in part, Master Treatment Plan-Within 72 hours of admission, the master treatment plan is completed.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 36 year old admitted to the hospital on 07/19/16 at 10:15 a.m. as a PEC for paranoid delusions about robots inside his body. The PEC indicated the patient was gravely disabled and unable to seek voluntary admission. Review of the Psychiatric Evaluation dated 07/20/16 revealed a diagnosis of Schizophrenia and the patient reported constantly hearing voices. Review of the psychiatric evaluation revealed the patient was compliant with medications.

Review of the patient's Treatment Plan revealed the RN initiated the plan on 07/19/16 at 11:35 a.m. Review of the Therapy Master Problem List revealed the only problem identified was "7/23/16 - increased auditory hallucinations." Review of the Treatment Plan revealed the problem was not initiated until 07/23/16, 4 days after admission (96 hours).

In an interview on 08/09/16 at 11:10 a.m. S4LMSW reviewed the patient's Treatment Plan and confirmed the problem/goal/interventions identified for the patient's psychiatric diagnosis was not initiated until 7/23/16, 4 days after hospital admission. She confirmed the Treatment Plan was not completed within 72 hours as directed in the hospital's policy.



Patient #2
Review of Patient #2 medical record revealed he was admitted to the hospital on 7/13/16 for Major Depression, recurrent severe with Psychotic Features and Polysubstance Abuse. With review of the Therapy Master Problem revealed the only problem listed was Alteration in Mood: Depression. With further review of the treatment plan revealed the date the problem was initiated was 7/17/16, approximately 4 days after admission (96 hours). Patient #2 was discharged on 7/19/16, his length of hospital stay was 6 days.

An interview was conducted with S3Clinical Director on 8/9/16 at 9:54 a.m. She reported the treatment plan for Patient #2 should have been completed the day before (7/16/16) according to the hospital's policy. She further reported the patients' treatment plans should have been completed by 72 hours after admission.


3. The hospital failed to include the patient in the development of the treatment plan of care:

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use.

Review of the written Treatment Plan revealed no documented evidence of the patient's Stated Goal for Treatment, no documentation of the Patient Needs, and no documentation of the Patient Preferences. There was no documented evidence that the patient participated in the development of the plan and there was no documented evidence the plan was explained to the patient. The signature line for the patient's signature on the Treatment Plan was left blank.

In an interview on 08/10/16 at 10:40 a.m., S3Clinical Director reviewed the Treatment Plan for this patient and confirmed there were no therapy problems identified in the Treatment Plan. S3Clinical Director confirmed the patient had not signed the Treatment Plan and there was no documented evidence the patient participated in the development of the Treatment Plan.




4. The hospital failed to ensure the patient's Treatment Plan included individualized, measurable goals and specific interventions for identified problems:

Review of the hospital policy titled, Interdisciplinary Treatment Planning - Overview, Policy # NU 453 revealed in part the following:
It is the policy that each patient admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 36 year old admitted to the hospital on 07/19/16 at 10:15 a.m. as a PEC for paranoid delusions about robots inside his body. The PEC indicated the patient was gravely disabled and unable to seek voluntary admission. Review of the Psychiatric Evaluation dated 07/20/16 revealed a diagnosis of Schizophrenia and the patient reported constantly hearing voices. Review of the psychiatric evaluation revealed the patient was compliant with medications.

Review of the patient's Treatment Plan revealed the RN initiated the plan on 07/19/16 at 11:35 a.m. Review of the Therapy Master Problem List revealed the only problem identified was "7/23/16 - increased auditory hallucinations." Review of the Treatment Plan Problem Sheet revealed a problem of "Disturbed Thought Processes as manifested by paranoia and hallucinations." The Long Term Goal was documented as, "Patient will gain insight into importance of medication compliance and verbalize less or no auditory hallucinations." Short Term goals were identified as, "Patient will attend group therapy daily to gain insight into coping skills for AH (Auditory Hallucinations)." Review of the identified interventions for this problem were: "increase coping abilities, and increase motivation." There was no documented evidence of any individualized specific interventions for the identified problem. There was no documented evidence of any measurable long term or short term goals.

In an interview on 08/09/16 at 11:10 a.m. S4LMSW reviewed the patient's Treatment Plan and confirmed there were no measurable goals identified and there were no specific individualized interventions identified in the Treatment Plan for the patient's psychiatric problems.


Patient #3
Review of the medical record for Patient #3 the patient was a 32 year old admitted to the hospital on 07/26/16 with a diagnosis of Bipolar Disorder, Depression. The record revealed the patient was a Formal Voluntary Admit from a group home.
Review of the Psychosocial Assessment revealed the reason for admission was, "Acting up" at the group home. The assessment revealed the patient was off his medications due to his Medicaid being stopped and he could not afford the medications.

Review of the patient's Treatment Plan revealed the patient's strengths were identified as Access to Resources, Good physical Health, Good Hygiene. Review of the Therapy Master Problem List revealed the only problem identified was, "Alteration in mood - depressed." Further review of the Treatment Plan revealed the only intervention identified for the problem of Alteration in mood, was, "Help patient cope with depression."

In an interview on 08/09/16 at 2:30 p.m. S10LMSW reviewed the patient's medical record and Treatment Plan and confirmed the patient's interventions were not individualized for this patient.

Based on record review and staff interview, the Hospital failed to ensure the patient's treatment plan was based on an inventory of the patient's strengths and disabilities for 2 (#4, #5) of 5 (#1-#5) sampled patient records.
Findings:

Review of the hospital policy, Interdisciplinary Treatment Planning Overview, Policy Number NU433 revealed in part, The first page of the interdisciplinary initial treatment plan includes...patients assets and strengths.

Patient #4
Review of Patient #4's medical record revealed she was admitted to the hospital on 6/2/16 for Bipolar, Depression Severe with Psychotic Features with Suicidal Ideation, Marijuana and Possible Cocaine Abuse. Review of the Psychiatric Evaluation dated 6/3/16 revealed the patient had a positive drug screen for Cocaine on admission to the hospital.

With review of the Patient #4's Treatment Plan dated 6/2/16, revealed the following patient's weaknesses: Limited support system, Marital Problems/Divorce, Noncompliance, Financial Problems, History of Treatment, and Poor Grades in school. Polysubstance abuse was not listed as a weakness.

An interview was conducted with S3Clinical Director on 8/9/16 at 3:10 p.m. With review of the patient's medical record she reported, substance abuse should had been documented as a weakness and included in Patient #4's treatment plan.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was admitted under a PEC dated 06/29/16 for being dangerous to self and others, and unable to seek voluntary admission.

Review of the Treatment Plan revealed no documented evidence of any patient strengths or patient weaknesses identified for the patient. Further review of the Treatment Plan revealed there was no documented evidence of any Therapy problems identified for the patient.

In an interview on 08/10/16 at 10:40 a.m., S3Clinical Director stated nursing was doing all the treatment plans until around beginning of March and then social services started doing their portion of the tx plan. After reviewing the Treatment Plan for this patient, S3Clinical Director confirmed there were no therapy problems identified in the Treatment Plan and there were no patient strengths or weaknesses identified in the Treatment Plan. S3Clinical Director stated during this time the staff was reduced to 2 social workers and they were short staffed.




26351

Based on record review and staff interview, the Hospital failed to ensure the written treatment plan included short-term and long range goals as evidenced by:
1. failing to identify the patient's mental health problems and failing to identify short and long term goals to address the patient's problems for 1 (#5) of 5 (#1-#5) sampled patients, and;
2. failing to ensure the written treatment plan included measurable short-term and long range goals for 2 (#2, #4) of 5 (#1-5) sampled patients.
Findings:

1. No Long term and short term goals in the Treatment Plan:

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was admitted under a PEC dated 06/29/16 for being dangerous to self and others, and unable to seek voluntary admission.

Review of the Treatment Plan revealed no documented evidence of any Therapy problems identified for the patient. There were no identified problems related to the patient's psychiatric diagnoses and there was no documented evidence of any short and long term goals related to the patient's psychiatric diagnoses.

In an interview on 08/10/16 at 10:40 a.m., S3Clinical Director reviewed the Treatment Plan for this patient and confirmed there were no therapy problems identified in the Treatment Plan and there were no short and long term goals related to the patient's psychiatric diagnoses identified in the Treatment Plan. S3Clinical Director confirmed the Treatment Plan was not done by social services. S3Clinical Director stated during this time the staff was reduced to 2 social workers and they were short staffed.


2. No measurable Long Term and Short term goals:

Patient #2
Review of Patient #2's medical record revealed he was admitted on 7/13/16 for Major Depression with recurrent severe with psychotic features and Polysubstance abuse.

Review of his treatment plan, dated 7/17/16, revealed the following Long Term Goal: Patient will develop healthy cognitions about self and ability to cope with stressors. Long Term Goal 2: Overall mood will be improved. Short term goals: Pt (Patient) will report improved sleep as an escape from reality. Will develop and use positive self talk.

An interview was conducted with S3Clinical Director on 8/9/16 at 9:54 a.m. She confirmed the above goals were not measurable.



Patient #4
Review of Patient #4's medical record revealed she was admitted to the hospital on 6/2/16 for Bipolar, Depression Severe with Psychotic Features with Suicidal Ideation, Marijuana and Possible Cocaine Abuse.

Review of the patient's Treatment Plan revealed the Therapy Master Problem List included one problem which was Depression. Patient #4 Long term goal for this problem was listed as Patient will develop healthy cognitions about self so that daily functioning is not impaired. Long Term Goal #2 Verbalize motivation to stay treatment compliant.

An interview was conducted with S3Clinical Director on 8/10/16 at 11:00 a.m. She reported these goals were not measurable.

Based on record review and staff interview, the Hospital failed to ensure the written treatment plan included the responsibilities of each member of the treatment team as evidenced by failing to identify responsibilities of the Social Worker and the Recreation Therapist in the treatment plan for 1(#5) of 5 (#1-#5) sampled patients.
Findings:

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was admitted under a PEC dated 06/29/16 for being dangerous to self and others, and unable to seek voluntary admission.

Review of the Treatment Plan revealed no documented evidence of any Therapy problems identified for the patient. There were no identified problems related to the patient's psychiatric diagnoses. Further review of the Treatment Plan revealed no documented evidence that Recreation/Activities were included in the patient's Treatment Plan. Review of the Treatment Plan revealed no documented evidence of the Social Worker and Recreation/Activity Therapist responsibilities in the Treatment Plan.

In an interview on 08/10/16 at 10:40 a.m., S3Clinical Director reviewed the Treatment Plan for this patient and confirmed there were no therapy problems identified in the Treatment Plan and there was no documented evidence of the responsibilities of the Social Worker and the Recreation/Activity Therapist. S3Clinical Director confirmed the Treatment Plan was not done by social services or the Recreation Therapist. S3Clinical Director stated during this time the staff was reduced to 2 social workers and they were short staffed.

Based on record review and staff interview, the Hospital failed to ensure each discharged patient had recommendations from appropriated services concerning follow-up aftercare as evidenced by failing to ensure verbal and written communication of patient information was provided to the aftercare provider for 1(#5) of 5 (#1-#5) sampled patients.
Findings:

Review of the hospital policy titled, Discharge Planning Process, Policy #PM 024 revealed in part the following: The therapist is responsible for completing the psychosocial aftercare plan with the patient prior to discharge....The social service staff is responsible for coordinating the discharge plan....Aftercare Plan: Tasks to be accomplished: Finalize arrangements for patient and family to enter continuing care program....

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was discharged on 07/05/16 at 10:50 a.m.
Review of the Discharge Care Plan and Home Medications form revealed an aftercare appointment was made with a mental health clinic. Further review of the Discharge Care Plan revealed the section titled Continuing Care Coordination revealed the section was left blank. This section of the form revealed, "*Must be transmitted within 24 hours of discharge and fax confirmation page must be retained in the medical record. The discharge plan was transmitted and shared with the following providers:" Review of the Discharge Plan revealed it was signed only by the RN.
Review of the Interdisciplinary Progress Note dated 07/05/16 at 10:50 a.m. revealed the social worker documented the patient's mother confirmed the patient had a home to return to and there were no weapons in the patient's home. There was no documented evidence of any other discharge instructions, planning or coordination with aftercare providers.

In an interview on 08/10/16 at 10:40 am S3Clinical Director reviewed the medical record for Patient #5 and stated, "It looks like social services was not involved in this discharge." S3Clinical Director stated it may have not been done because the social worker was not available when the patient was discharged. After reviewing a calendar, she stated social services were not working the day the patient was discharged. S3Clinical Director stated, "It's not good, but that's the reason." S3Clinical Director stated the aftercare appointment was made prior to the date of discharge and confirmed patient information was not sent to the aftercare provider as required. She confirmed the social worker should have faxed patient information to the provider and documented that in the Continuing Care Coordination section. S3Clinical Director stated the social worker should have signed the Discharge Care Plan and Home Medications form on the day of discharge.

17091

Based on record review and staff interview, the Hospital failed to ensure adequate numbers of qualified professional personnel were employed to formulate written individualized comprehensive treatment plans for 1 (#5) of 5 (#1-#5) sampled patient records.
Findings:

An interview was conducted with S3Clinical Director on 8/9/16 at 9:54 a.m. She reported her job duties included supervising the case managers and assisting with the discharge planning and treatment plans. She reported the hospital has been short staffed with case managers to do discharge planning and treatment plans. She went on to report currently each social worker has between 15- 20 patients workload and the ideal workload would be 10 patients per social worker. She further reported she was covering the weekend with prn (as needed) social workers.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. The record revealed the patient was admitted under a PEC dated 06/29/16 for being dangerous to self and others, and unable to seek voluntary admission. Review of the physician orders dated 06/30/15 revealed Alcohol Detox standing orders were prescribed.

Review of the Treatment Plan revealed no documented evidence of any Therapy problems identified for the patient. There were no identified problems related to the patient's psychiatric diagnoses or Poly-Substance abuse, and there was no documented evidence that the alcohol detox was included in the written Treatment Plan.

In an interview on 08/10/16 at 10:40 a.m., S3Clinical Director reviewed the Treatment Plan for this patient and confirmed there were no therapy problems identified in the Treatment Plan and the Alcohol Detox was not included in the Treatment Plan. S3Clinical Director confirmed the Therapy problems were the responsibiltiy of social services, and the Treatment Plan was not done by the social worker. S3Clinical Director stated during this time the staff was reduced to 2 social workers and they were short staffed.

Based on record review and staff interview, the Director of Nursing failed to ensure the RN directed, monitored and evaluated the nursing care furnished as evidenced by:
1) The RN failing to ensure the Registered Dietician (RD) conducted a dietary consult as ordered by the physician for 1 of 1 (#5) sampled patients with a RD consult ordered out of a total sample of 5 (#1-#5), and;
2) The RN failing to monitor the vital signs of an Alcohol Detoxification patient as ordered by the physician for 1 of 1 (#5) sampled patients with Alcohol Detoxification orders out of a total sample of 5 (#1-#5).
Findings:


1) The RN failing to ensure the Registered Dietician (RD) conducted a dietary consult as ordered by the physician:

Review of the Hospital's policy titled Nutritional Screening-Assessment-Consultations, Number: CTS-043, provided by S2DON as the hospital's policy for RD consults, revealed in part the following: All patients will receive nutritional screening via the nursing section of the comprehensive assessment process. A nutritional assessment is completed for patients determined to be at nutritional risk. The assessment is completed by a dietician within 72 hours of notification by dietary with the receipt of a physician's order....The dietician communicates the findings of the assessment and consultations in the Progress Notes or on the consultation form, which is placed in the patient's chart for integration into the treatment planning process.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 with diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use.
Review of the Nursing Admission Assessment dated 06/30/15 at 8:55 p.m. revealed, "Nutritional Screen Total Risk Score 13 (10+ High Risk Consult Dietician) Consult Needed: Yes." Further review of the Nutritional Screen section revealed, "Consult placed 06/30/16" was hand written in.
Review of the Physician Orders dated 06/30/16 at 8:55 p.m. revealed an order to consult the dietician for a diagnosis of Diverticulitis.

Further review of the patient's record revealed no documented evidence that the RD consult was done.

In an interview on 08/10/16 at 11:25 a.m., S2DON reviewed the physician's orders and the initial nursing assessment and confirmed the nutritional screen had identified the patient was a high risk and an RD consult was needed. S2DON confirmed the physician ordered a RD consult on 06/30/16. After reviewing the entire medical record, S2DON confirmed there was no documented evidence that a Dietary consult was done for this patient. When asked how the Dietician was notified of a consult, she stated they usually just call S6Dietician as she is in the hospital Monday through Friday and she usually comes within the hour. S2DON then stated she was not sure how the RD consult was handled. S2DON confirmed the order was written at 8:55 p.m. and S6Dietician not in the hospital at that time. At 11:48 a.m., S2DON returned and stated that the staff call S6Dietician, leave a message, or leave an order or a consult form in her box. S2DON provided a 3-4 inch stack of orders and consult sheets and stated these documents were the consults S6Dietician had received. S2DON stated she was unable to find any documentation that the RD was notified of the consult for Patient #5. S2DON confirmed the patient's Dietary Consult was not done and she confirmed nursing staff were responsible for ensuring the consults were done.


2) The RN failing to monitor the vital signs of an Alcohol Detoxification patient as ordered by the physician:

Review of the hospital policy titled, Detoxification, Policy #NU 415 revealed in part the following: If the patient is considered by the treatment team and the medical staff to be medically stable and a blood alcohol level below 100, detoxification procedure may take place. Contact physician for appropriate detox protocol.

Patient #5
Review of the medical record for Patient #5 revealed the patient was a 30 year old admitted to the hospital on 06/30/16 diagnoses of Schizoaffective Disorder, Bipolar Type and Poly-Substance Use. Review of the record revealed the patient had an Alcohol level of 89 and a Urine Drug Screen positive for Cocaine on admission.

Review of the Physician Orders dated 06/30/16 at 8:55 p.m. revealed a verbal/telephone order was received for the standing orders for "Orders-ETOH (Alcohol) Detox." Review of the Alcohol Detoxification orders revealed an order for Vital Signs every 4 hours for 3 days.

Review of the medical record revealed the only place in the record vital signs were documented was on the Vital Signs Flowsheet. Review of the Vital Signs Flowsheet revealed no documented evidence that the patient's vital signs were monitored from 06/30/16 at 11:00 p.m. to 07/01/16 at 6:00 a.m. (7 hours later). Further review of the Vital Signs Flowsheet revealed the vital signs were only monitored every 12 hours for the next 3 days.

In an interview on 08/10/16 at 11:25 a.m., S2DON reviewed the medical record for Patient #5 and confirmed the Alcohol Detox orders indicated vital signs were to be done every 4 hours for 3 days. After reviewing the patient's record page by page, she confirmed the only place vital signs would be documented were on the Vital Signs Flowsheet. S2DON confirmed the vital signs were not monitored every 4 hours for 3 days as ordered by the physician.

Based on record review and interview, the hospital failed to ensure competent direct care worker were providing patient care as evidenced by 1 out of 1 RN (S8RN) personnel file reviewed failed to have skill competencies documented and 1 (S7MHT) out 2 MHT (S7MHT and S9MHT) personnel files reviewed failed to have documentation of skill competencies. Findings:

Review of the hospital's policy on Staff Competency, Policy Number HR.012 revealed in part, Purpose to provide a method of evaluating staff's level of competency within an assigned department and job description. III. Procedure Method of assuring staff competency....3. Skills Check List, department, and/or population specific.

Review of the personnel record for S7MHT revealed her date of hire was 5/04/16. With further review of her personnel records revealed no documentation of her skills compentencies.

Review of the personnel record for S8RN revealed her date of hire was 07/06/16. With further review of her personnel records revealed no documentation of her skills competencies.

An interview was conducted with S2DON on 8/10/16 at 1:00 p.m. She reported she did not have documentation of S7MHT and S8RN skill competencies.