HospitalInspections.org

Based on record reviews, observations, hospital policies and interviews the facility failed to assure:

A. Care was provided in a safe setting to include:

1. The patients' rooms were clean.
2. Furniture and fixtures were continually maintained and safe for the patients to use.
3. Safety locks were not available for patient use in patient care areas.
4. Seclusion room was occupied only when ordered.

Refer to A 144

B. Patients were free from abuse/harassment. The facility failed to:

1. Follow their policy on possible patient abuse and investigated the allegation timely.

2. Provided a safe environment for an adolescent patient who had an altercation with a staff member.

3. Documented a complete investigation and resolution for an incident between a patient and a staff member.

4. Reassigned a nurse who was involved in an incident/altercation with a patient.

Refer to A 145

C. The physician signed orders for restraint.

Refer to A 168

This had the potential to affect all patients served by this facility.

Based on observation and interview with administrative staff it was determined the facility failed to:

1. Ensure the patients' rooms were clean.
2. Ensure furniture and fixtures were continually maintained and safe for the patients to use.
3. Ensure safety locks were not available for patient use in the patient care areas.
4.Ensure the seclusion room was occupied only when ordered.

This had the potential to affect all patients.


Findings include:

On 8/15/11 at 1:15 PM, the surveyors conducted a tour of the first floor of the hospital which housed the adolescent girls.

The following was observed:

In the break room, where the adolescent girls eat their meals, the air conditioner vent was broken. There were bare coils and metal ends that exposed hazardous areas that posed a potential harm to patients.

The shower areas contained two shower stalls which had shower curtains that did not breakaway thus leaving hazardous areas in which a patient could harm themselves.

In patient room 106 and 112 the air conditioner vent had metal exposed which caused a potential hazardous area that could harm patients.

On 8/15/11 at 1:30 PM, the surveyors conducted a tour of the third floor of the hospital which housed the adolescent boys and children.

The following were observed:

The bathroom between patient rooms 302 and 304 had twist locks on either side which would allow a patient to be locked into the bathroom with no way out.

In patient room 326 the entire air conditioner vent was off leaving bare coils which caused a potential hazardous area in which patients could harm themselves.

In patient room 328 the air conditioner vent had pulled up edges which caused a potential hazardous area in which patients could harm themselves.

The above observations were verified by Employee Identifier (EI) # 1, Chief Operations Officer and EI # 2, the Director of Services during the tour.

An observation of the seclusion room on the children's wing on 8/15/11 at 1:40 PM, revealed a bed made up with a bottom and top sheet, bed spread and pillow. There were 2 used Band-Aids on the floor. When the surveyors asked who had been using the seclusion room as a bedroom none of the staff could verify the name of the patient or when they had occupied the seclusion room. After approximately 10 minutes of reviewing records and talking with patients, the staff stated a patient used the room on the night of 8/11/11. The surveyor then asked why the room had not been cleaned in 4 days, no response was given. EI # 1 and 2 then directed the housekeeping department to clean the seclusion room.

A second observation of the seclusion room after cleaning by the housekeeping department on the children's wing on 8/15/11 at 1:50 PM, revealed the bed had been made up with the same bottom sheet as evidenced by cereal crumbs on the bottom sheet. This was verified by EI # 2.

During a second tour of the third floor of the hospital on 8/17/11 at 2:00 PM, it was noted the seclusion room bed had metal brackets (for the use of restraints) hanging down which were exposed and presented a cutting hazard.

Based on review of medical and personnel records, facility policy and procedure and interview with administrative staff it was determined the facility failed to:

1. Follow their policy on possible patient abuse and investigate the allegation timely.

2. Document a complete investigation and resolution of the alleged incident between a patient and staff.

3. To reassign the nurse involved in an incident with a patient while an investigation was being conducted.

This has the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 2.

Findings include:

Facility Policy: Identifying and Reporting Patient Abuse and Neglect

Policy: It is the policy of ... that any instances of physical, psychological, sexual or any other abuse by any employee or any professional staff... toward a patient will not be tolerated. All employees are expected to report any suspected patient abuse or neglect to their immediate supervisor or the Chief Executive Officer on an Incident report.

Procedure:
B. Penalties for discipline are determined through investigation by the Chief Executive officer and the respective Department Manager.
3. Penalties to be imposed shall consist of one of the following, based upon the investigation conducted by the Chief Executive Officer, Department Head and/or supervisor(s).
a. Official reprimand
b. Reassignment
c. Demotion
d. Suspension
e. Dismissal

E. Staff Responsibilities:
1. Hospital staff
a. Staff receiving or witnessing an incident of patient abuse or neglect must report the incident to their immediate supervisor or the Chief Executive Officer by filing an incident report...
b. Document all information concerning the incident on the Incident Report form being as descriptive as possible.
c. Submit completed Incident Report to their immediate supervisor who brings the incident report to the Chief Executive Officer.

2. Upon receipt of the completed Incident Report form that alleges patient abuse or neglect, the Director of Patient Services will contact the Hospital Chief Executive Officer and:
a. Shall investigate all complaints as soon as administratively possible.
b. Ascertain that all substantial allegations in a complaint shall remain open until adequate remedial action has been provided.

3. Chief Executive Officer
a. Upon receipt of an incident report or complaint that alleges employee, family or patient abuse or neglect, will meet as soon as possible with the supervisor.
d. Shall conduct a disciplinary hearing with involved staff and issue penalties.
f. Files the incident report in the professional, employees or contract employees personnel file.

4. Hospital Executive Committee:
a. Shall review all data in relation to allegations of patient abuse/neglect.
b. Shall interview all staff involved or who has knowledge of the allegations of patient abuse/neglect and ascertain if the patient's rights have been violated.
c. Shall make written recommendations to the Chief Executive Officer for remedial action.

Facility Policy: Quality Assurance Reporting

Purpose:
To provide a mechanism for reporting hospital occurrences related to patient/employee safety.

Policy:
All occurrences on or within Corporate property should be reported to an immediate supervisor/ physician and documented in the patient record when appropriate. A Quality Assurance Report will be completed and forwarded to the Risk Manager for follow-up.

The following occurrences should warrant completion of an Quality Assurance Report, but is not inclusive:
1. Patient injury, patient abuse, or patient emergency
2. Visitor injury
3. Employee injury
4. Falls
5. Injuries resulting from Restraint/ Seclusion


Patient findings:

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

An incident report dated 6/2/11 by Employee Identifer (EI) # 4, the Nurse Manager documented an altercation between the floor nurse and a female patient. Attached to the incident report were statements from EI # 4 on 6/7/11 when interviewed by the nurse manager. Two of the Psychiatric technicians involved provided written statements 6/8/11 and written statements were obtained from EI # 3, Registered Nurse (RN) # 1 and EI # 5, RN # 2 on 6/25/11. Two other Psychiatric technicians involved provided written statements 6/8/11 and 6/25/11. The house supervisor was not asked to complete a statement regarding the incident nor was the male Psychiatric technician who responded to the Code Yellow asked to document his observations.

During an interview on 8/15/11 at 12:30 PM with EI # 10, Director of Human Resource, he was asked why it was 6/25/11 before the statements of the two RN's were obtained. EI # 10 stated, " I can't remember why it took so long to get their statements."

EI # 10 was asked why the incident report was started by the Nurse Manager, EI # 4 on 6/2/11 and signed off on 6/7/11. EI # 10 stated that EI # 4 just started the Incident report and he completed it 6/25/11 after he received the two RNs' statements.

There was no documentation in the personnel file of the nurse involved in the altercation with the patient when reviewed by the surveyor 8/17/11.

An interview was conducted on 8/16/11 at 8:05 AM, with EI # 3, RN # 1 who was involved in the altercation with PI # 2 on 6/2/11. EI # 3 was asked if she completed an incident report concerning the incident. EI # 3 stated that she completed an incident report before the end of her shift the early AM of 6/3/11 and asked two of the Psychiatric Technicians who worked with her that night to sign it and then she put it under the door of the Nurse Manager.

An interview was conducted on 8/16/11 at 7:10 AM, with EI # 6, Psychiatric Technician, she was asked who asked her to complete a statement concerning the incident. EI # 6 stated it might have been the Nurse Manager on 6/7/11 because I did it and turned it in 6/8/11. EI # 6 was asked if an incident report was completed by the nurse involved. EI # 6 stated that she signed an incident report that was completed by EI # 3, any of the people involved had to sign it.

The incident report completed by EI # 3 the RN involved in the altercation with PI # 2 was not located while the surveyor was onsite. The Nurse Manager stated that she did not see an incident report under her door 6/3/11 when she came into work.

In an interview with EI # 4 on 8/15/11 at 12:30 PM, the surveyor asked when EI # 3 was moved to another unit. EI # 4 stated, " When I met with her 6/7/11, I told her she should not work with PI # 2. She worked with her even though I told her not too."

A review of the Child and Adolescent schedules for the month of June confirmed the nurses were not assigned to a specific area to work except for the schedule dated 6/29/11 which documented EI # 3 was to work 4 th floor residential.

A review of the medical record confirmed EI # 3 worked with PI # 2 on 6/2/11, 6/6/11, 6/7/11, 6/10/11, 6/12/11, 6/15/11, 6/16/11, 6/20/11, 6/21/11, 6/24/11 and 6/25/11.

During an interview with EI # 2, the Director of Clinical Services she confirmed that she had a conversation on 6/29/11 at 5:10 PM and instructed EI # 3 that upon return to work she would be working on Adult unit or residential unit and that she was not to go on the third floor where PI # 2 was located. The facility failed to ensure EI # 3, the nurse involved in the incident with PI # 2, was reassigned to a different area.

Based on a review of medical records, facility policy and procedures and interview with Employee Identifer( EI) # 1, the Chief Operations Officer and EI # 4 the Nurse Manager it was determined the facility failed to assure the physician signed orders for restraint. This had the potential to affect all patients served by this facility and did affect Patient Identifer # 2.

Facility Policy: Restraints and Seclusion

Section Three: Physician Orders for Restraint and Seclusion and Evaluation
If the Registered Nurse (RN) initiates the restraint or seclusion, as soon as possible, but no longer than one hour, the Registered Nurse must notify and Obtain an order from the Psychiatrist... The Psychiatrist or trained Registered Nurse will do the following:
1. Reviews with the RN the physical and psychological status of the patient.
2. Determine whether restraint or seclusion should be maintained.
3. Supplies staff with guidance in identifying ways to help the patient regain control so that restraint or seclusion can be discontinued.
4. Supplies a time-limited order.

Facility Policy: Physician's Orders
Procedure:
C. Verbal and telephone orders must be authenticated within twenty-four hours.

Patient Findings:

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

A certified copy of PI # 2's medical record was given to the surveyor on 8/16/11 with the form signed 8/15/11 by the Custodian of Records.

On reviewing the orders for restraint and seclusion it was observed that the orders dated 5/29/11, 6/2/11, 6/5/11, 6/9/11 and 7/10/11 were not authenticated by the physician within 24 hours.

During an interview with EI # 4, the Nurse Manager on 8/18/11 at 9:30 AM, EI # 4 stated, "All of the orders are signed except 6/5/11 and no date was on the 6/9/11 order." The surveyor asked when the orders were signed as the certified copy of the medical record received 8/16/11 and the orders were not signed. EI # 4 said she did not know and produced signed orders dated as follows: the 5/29/11 order was signed by EI # 8, the Medical Director and dated 5/29/11, the 6/2/11 restraint and seclusion order was signed by EI # 8 and dated for 6/30/11 and the 6/9/11 order still does not have a date or time it was signed.

EI # 1, the Chief Operations Officer confirmed the orders were not signed in the copies of the medical record the surveyor received 8/16/11.

Based on record review and interview with the staff, it was determined the facility failed to ensure the medical records reflected the accurate admission date in 1 of 1 closed records reviewed of a patient that was admitted to the acute care hospital from the residential care unit associated with the facility. This affected Patient Identifier (PI) # 3 and had the potential to affect all patients served by this facility.

Findings include:

1. PI # 3 was determined to be admitted to the facility on 5/6/11 or 5/7/11 with diagnoses including Mood Disorder and Impulse Control Disorder. This patient has a history of Major Depressive Disorder,Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Relative Attachment Disorder.

Review of the Discharge Summary dictated 6/6/11 revealed documentation the patient was admitted on 5/7/11.

Review of the admission Physician Orders revealed a date of 5/6/11 at 19:15.

Review of the Restraint/Seclusion Protocol MD (physician) Orders revealed an order dated 5/6/11 at 16:15.

An interview was conducted with Employee Identifier # 1, the Chief Operations Officer on 8/17/11 at 1:00 PM. The surveyor asked what date the patient was admitted to the facility and the response was, "the patient was a residential client and transferred to the acute care hospital on 5/6/11 and the acute care would not read the admission date until 5/7/11 due to billing purposes". The admission date was determined to be 5/6/11, however the medical record failed to reflect the actual admit date.

Based on review of medical records, interview with Employee Identifer (EI) #1, the Chief Operations Officer and EI # 4, Nurse Manager and facility policy it was determined the physician failed to sign the physician orders within twenty four hours per the facility's policy and to date and time them when they were signed. This had the potential to adversely affect all patients served by the facility.


Facility Policy: Physician's Orders
Procedure:
C. Verbal and telephone orders must be authenticated within twenty-four hours.

Patient Findings:

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

A certified copy of PI # 2's medical record was given to the surveyor on 8/16/11 with the form signed 8/15/11 by the Custodian of Records.

On reviewing the orders for restraint and seclusion it was observed that the orders dated 5/29/11, 6/2/11, 6/5/11, 6/9/11 and 7/10/11 were not authenticated by the physician within 24 hours.

During an interview with EI # 4, the Nurse Manager on 8/18/11 at 9:30 AM, EI # 4 stated, " All of the orders are signed except 6/5/11 and no date was on the 6/9/11 order." The surveyor asked when the orders were signed as the certified copy of the medical record received 8/16/11 and the orders were not signed. EI # 4 said she did not know and produced signed orders dated as follows: the 6/2/11 restraint and seclusion order was signed by EI # 8, the Medical Director and dated for 6/30/11, the 5/29/11 order was signed by EI # 8 and dated 5/29/11, the 6/9/11 order still does not have a date or time it was signed.

A review of other physician orders that were not signed included the following:
6/15/11, 6/21/11, 6/22/11, 7/7/11, 7/10/11, 7/22/11, 8/8/11 and 8/2/11.

EI # 1 confirmed the orders were not signed in the copies of the medical record the surveyor received 8/16/11.

The orders observed in the medical record that were signed by the physician were not consistently dated and timed, only the restraint orders were dated with the exception of the 6/9/11 restraint order.



17650

2. PI # 3 was admitted to the facility on 5/6/11 with diagnoses including Mood Disorder and Impulse Control Disorder. This patient has a history of Major Depressive Disorder,Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Relative attachment Disorder.

Review of the physician orders dated 5/6/11(restraint/seclusion), 5/7/11, 5/8/11, 5/9/11 x 2 orders, 5/13/11 x 2 orders, 5/17/11, 5/23/11 (restrain/seclusion), 5/24/11 (restraint/seclusion), 5/26/11 (restrain/seclusion), 5/27/11, 5/28/11, 5/29/11 (restrain/seclusion),5/30/11, 6/1/11, and 6/2/11 x 3 orders revealed no documentation of a date and time the physician authenticated the orders.

An interview was conducted on 8/17/11 at 2:10 PM with EI # 9, the Counselor and EI # 4 who verified the above.

3. PI # 1 was admitted to the facility on 10/25/10 with diagnoses including Depressive Disorder and Inhalant Abuse.

Review of the Admission Physician Orders dated 10/25/10 revealed no documentation of a physician's signature for authentication.


Review of the physician orders dated 10/26/1011/3/10, 11/4/10, 11/7/10, 11/8/10, 11/9/10, 11/16/10 (restraint/seclusion)11/13/10, 11/15/10, and 11/17/10 revealed no documentation the physician signed and dated to authenticate the verbal orders.

An interview was conducted on 8/18/11 at 9:20 AM with EI # 9, the Counselor and EI # 4 who verified the above.

Based on the review of the Alabama Board of Nursing, Standards of Practice and medical records and interview with the staff, it was determined the facility failed to ensure the nursing staff followed the Alabama Board of Nursing, Standards of Practice for medication administration. This had the potential to affect all patients served by this facility and did affect 1 of 1 open records reviewed, Patient Identifier (PI) # 2.

Findings include:


Refer to 420-5-1-.02(8)(a) Records and Reports
Alabama Board of Nursing, Standards of Practice
Chapter 610-X-6-.06 Documentation Standards (d)(iii)
(d) Timely.
(i) Charted at the time or after the care, including medications, is provided...
(ii) Should the registered nurse or licensed practical nurse add documentation that was omitted, the documentation shall reflect " late entry" including a date and time the late entry was made as well as the date and time the care was provided.

Alabama Board of Nursing, Standards of Practice
Chapter 610-X-6-.07 Medication Administration and Safety (1)(j)
Safety precautions including but not limited to:
(i) Right patient
(ii) Right medication
(iii) Right time
(iv) Right dose
(v) Right route
(vi) Right reason
(vii) Right documentation

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

Review of the Physician's Order dated 5/29/11 revealed an order for Benadryl 25 mg. (milligrams) PO (by mouth) for c/o (complaints of) inability to sleep per "sleep hygiene" request.

Review of the MARs (Medication Administration Record) for the month of May revealed no documentation of the physician's order for the Benadryl dated 5/29/11.

Review of the MAR for the month of June revealed an entry dated 6/2/11 reading, "Benadryl 25 mg po @ (at) HS (hour of sleep) PRN (as needed) in accordance c (with) sleep hygiene". Review of the physician's orders revealed no documentation of an order for the above noted Benadryl.

Further review of the MAR for June revealed Employee Identifier # 3, which is Registered Nurse (RN) # 1 documented the administration of Benadryl 25 mg PO at 22:10 on 6/2/11.

An interview was conducted with EI # 3 on 8/16/11 at 8:00 AM. The surveyor asked EI # 3 to explain what happen on 6/2/11. EI # 3 stated the patient wanted a PRN for sleep. EI # 3 stated she/he pulled the Benadryl from the medication system and handed it to PI # 2. PI # 2 refused to take the Benadryl at that time and an altercation broke out. The surveyor asked where the Benadryl was during the altercation and EI # 3 stated it ended up against the wall on the counter. EI # 3 stated that EI # 5 (RN # 2) came over to help with the altercation and asked if she/he needed to give PI # 2 the Benadryl.

An interview was conducted with EI # 5 on 8/16/11 at 7:35 AM. EI # 5 stated that she/he administered the Benadryl after EI # 3 had left the floor.

Further review of the June MAR revealed a late entry by EI # 5 dated 6/7/11 for 6/2/11, with no documentation of the time the Benadryl was administered.

Review of the June MAR revealed EI # 3 administered Benadryl 25 mg on 6/12/11 at 22:05, 6/20/11 at 22:05 and 6/24/11 at 20:24. Further review of the MAR for June revealed EI # 5 administered Benadryl 25 mg on 6/7/11 at 22:53, 6/21/11 at 20:35 and 6/30/11 at 21:10. There was no documentation of a physician's order for the use of Benadryl after May 29, 2011.

Review of the MAR for the month of July revealed the Registered Nurses administered Benadryl 25 mg on 7/4/11 at 21:05 and 7/12/11 at 21:20. There was no documentation of a physician's order for the use of Benadryl after May 29, 2011.

The surveyor requested the policy for Medication Administration on 8/18/11 from EI # 1, the Chief Operation Officer and the following statement was submitted, "It is the standard practice of Mountain View Hospital to follow the Alabama Board of Nursing, Nurse Practice Act and the Alabama Administrative Code for all nursing procedures performed at this facility". This information provided to the surveyor 8/18/11, had no title or date of approval by the governing body.

EI # 3 failed to ensure a physician's order was valid before medication was administered to a patient. EI # 3 also documented administration of medication that EI # 3 stated she/he had not given on 6/2/11.

Based on review of medical records, review of policy and procedures and interview with Employee Identifier (EI) # 4, the Nurse Manager, it was determined in 1 of 1 open records 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 Patient Identifier (PI) # 2 and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Master Treatment Plan

Policy: To provide a comprehensive individualized and multidisciplinary plan of treatment for each patient.

Procedure:

1. The Master Treatment Plan (MTP) problem list will be initiated for each patient upon admission by the RN (Registered Nurse) on the unit per physician assessment.

2. Upon completion of patient assessment, the RN on the unit will initiate the objectives and modalities of treatment and complete within 24 hours.

4. The MTP will be completed and reviewed/revised by the treatment team according to the following schedule:
- completed within 5 days of admission
- reviewed every seven days of each patient's admission until discharge for each patient.

Instructions for completing MTP:

Discharge Goal: This is a measurable, specific goal for discharge identified for each problem listed.

Date: This is the date that the team member identified the short term goal for each identified problem.

Goal: This is the number for each short term goal listed.

Short term goal stated in behavioral terms: A short term goal describes incremental steps that the patient must achieve in order to reach the discharge criteria identified upon admission and/or during treatment team meetings. These are not objectives for the staff, but for the patient. Short term goals are written in a language that describes the patient's observable behavior in a measurable way.

Plan (Modality/ Frequency/ Approach);

Treatment plan or modalities are specific services, treatments, or therapy that the patient will receive or participate in. These interventions are the actions and approaches to be taken by staff in assisting the patient in obtaining the short term goals and working toward resolutions of the identified problem. This plan must include how often one will do the specific intervention.

Target date:
The staff and patient's estimate of when the short term goal will be achieved.

Date Resolved/ Deferred:

This is the date upon which the stated short term goal has been reached or deferred to outpatient care. This should be filled out during treatment team meetings but can be revised during the patient's course of treatment.

Patient findings:

1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

The Master Treatment Plan was dated 1/20/11 with the following information:

Goal # 1 - short term objectives- pt(patient) and staff will remain free from harm while at ...
Interventions: 1. search pt and belongings 2. provide every 15 minute safety vs(visits?) 3. give meds( medications) as prescribed 4. contact MD( Medical Doctor) for changes in pt mood or behavior 5. provide 1:1 with pt each shift and prn ( as needed) to express feelings and identify coping skills.
Target dates listed 2/3/11, 5/11/11, 5/16/11, 5/23/11, 5/30/11, 6/7/11, 6/15/11, 6/22/11, 6/28/11, and 7/15/11. There was no documentation of any change being made to the interventions for Goal # 1 from 1/20/11 when it was identified through 8/18/11.

The interventions for number 1 and number 3 were no longer in use as the search was done on arrival and all routine medications were discontinued at the request of the parents by May 2011. The patient remained on 1:1 observation for her safety according to the physician's progress notes.


Goal # 2 - short term objectives- pt will process emotions and improve her coping skills.
Interventions: 1. individual sessions to help patient identify underlying emotions that exaggerate her difficulties with relationships and coping skills. Pt will develop and practice at least some positive coping skills.
Target dates listed 2/3/11, 5/11/11, 5/16/11, 5/23/11, 5/30/11, 6/7/11, 6/15/11, 6/22/11, 6/28/11, and 7/15/11. There was no documentation of any change being made to the interventions for Goal # 2 from 1/20/11 when it was identified through 8/18/11.


The patient refused to attend individual therapy, group therapy and did not participate on a regular basis with the counselors. The patient continues to have issues with behavior problems, dealing with peers and coping through out the admission.


Goal # 3 - short term objectives- client will attend AT( activity therapy)/ ABC (Adventure based counseling) 7 times a week.
Interventions: client will complete activities, games, tasks and have elevated challenges with increased positive reality activity.
Target dates listed 2/3/11, 5/11/11, 5/16/11, 5/23/11, 5/30/11, 6/7/11, 6/15/11, 6/22/11, 6/28/11, and 7/15/11. There was no documentation of any change being made to the interventions for Goal # 3 from 1/20/11 when it was identified through 8/18/11.


The patient refused to participate in activities frequently and activities are only offered 5 times a week according to available documentation.


Goal # 4- the date for this goal was 2/24/11- short term objectives-... will attain sleep pattern/ hrs (hours) related to rest without greater than 9-10 hrs sleep per day.
Interventions: 1. monitor pt sleep every 15 minutes and prn 2. notify MD if pt exhibits s/s (signs/ symptoms) hypersomnia without medication 3. administer Rx (medication) for hypersomnia if MD ordered prn.
Target dates listed 4/29/11, 5/11/11, 5/16/11, 5/23/11, 5/30/11, 6/7/11, 6/15/11, 6/22/11, 6/28/11, 7/15/11 and 7/18/11. There was no documentation of any change being made to the interventions for Goal # 4 from 2/24/11 when it was identified through 8/18/11.


The patient is only allowed to receive Benadryl with the approval of a parent after the sleep hygiene program has been offered and completed; number 3 does not apply as written. Patient continues to ask for medication to help her sleep periodically and also continues to have issues with sleeping.


Goal # 5- short term objective- pt will exhibit improved mood and affect, verbalize positive coping skills, compliance with medication regimen and gaining insight into her mental well being.
Interventions: MD will Rx (treat) with mood stabilizing medications to alleviate distress and see pt daily to evaluate response.
Target dates listed 3/2/11, 5/11/11, 5/16/11, 5/23/11, 5/30/11, 6/7/11, 6/15/11, 6/22/11, 6/28/11, 7/15/11 and 7/18/11. There was no documentation of any change being made to the interventions for Goal # 4 from 2/24/11 when it was identified through 8/18/11. The patient has been on no regular medications since May 2011.


The patient is no longer on regular routine medications per request of the parents, therefore the interventions no longer apply to her needs.


Goal # 6 was added 5/2011 the day could not be read- short term objectives- ... will complete classwork on unit and earn blue level 4/5 days.
Interventions: Review appropriate participation/behaviors, study techniques, encourage active participation, give positive feedback.
Target dates listed 5/30/11, 6/7/11, 6/15/11, 6/22/11, 6/28/11, 7/15/11 and 7/18/11. There was no documentation of any change being made to the interventions for Goal # 4 from 5/2011 when it was identified through 8/18/11.


The patient often refused to attend the classroom and participate in school work. This has shown some improvement over the past few months but still continues to be erratic in participation and following direction.


The weekly treatment team meeting 6/14/11 documented regression in Goals # 2, 3, and 5 with minimal progress in Goal # 6. This weekly treatment team meeting was not signed as having been attended by the psychiatrist, therapeutic educator or patient.


The weekly treatment team meeting 6/21/11 documented moderate progress in all 5 goals marked on the form. This weekly treatment team meeting was not signed as having been attended by the psychiatrist, therapeutic educator or patient.


During an interview with EI # 4, the Nurse Manager on 8/18/11 at 9:35 AM, she confirmed they needed to work on addressing the goals and interventions.


No long term goals were documented on the treatment plan for PI # 2 who has been hospitalized since 1/19/11.

Based on record review and interview with the staff, it was determined the facility failed to follow the patient's established treatment plan for activities in 1 of 2 closed records reviewed. This affected Patient Identifier (PI) # 1 and had the potential to affect all patients served by this facility.

Findings included:

1. PI # 1 was admitted to the facility on 10/25/10 with diagnoses including Depressive Disorder and Inhalant Abuse.

Review of the treatment plan revealed an entry dated 10/28/10 which included Client will attend activities 7 x weekly. The interventions stated the client will complete activities, games, tasks, and complete challenges to increase positive mood.

Review of the activities reports and nurses' notes revealed no documentation of PI # 1 being offered activities on 10/31/10, 11/4/10, 11/5/10, 11/6/10, 11/7/10, 11/8/10, 11/9/10, 11/13/10, 11/14/10, 11/15/10, and 11/16/10.

An interview was conducted with Employee Identifier (EI) # 4, the Nurse Manager and EI # 9, the Counselor when the surveyor requested the Activities Report for the above days and none could be provided.

Based on review of medical records and interview with Employee Identifier (EI) # 4, the Nurse Manager, it was determined in 1 of 1 open records the progress notes by the physician failed to document a response to the treatment plan goals and were not signed and dated by the physician. This affected Patient Identifer (PI) # 2 and had the potential to affect all patients being served by this facility.

Findings include:


1. Patient identifier (PI) # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

The following progress notes are not signed in the certified medical record received by the surveyor 8/16/11:

6/15/11- MD ( medical doctor) note seen on rounds by Dr( doctor)... pt ( patient) nonverbal except for, " I'm fine". Will continue to monitor. 1:1 observation continues.

6/16/11- 0945 MD note, seen on rounds by Dr... pt states, " I'm fine". No c/o ( complaints of) voiced will continue to monitor.

6/17/11- 1000 MD note, seen on rounds by Dr... pt sleeping no complaints voiced- (refuses to talk) no behavioral problems reported by staff.

6/18/11- Patient seen on rounds today by Dr... sleeping no distress reported. Continue current treatment plan.

6/19/11- Patient seen on rounds by Dr... No distress noted, continue current treatment plan.

6/20/11 1250 MD note, seen on rounds by Dr... pt drowsy states, " I'm okay." No complaints voiced. Continue to monitor.

6/21/11- 0930 MD note, seen on rounds by Dr... requests STD ( sexually transmitted disease) testing but wants privacy maintained. No complaints voiced will continue to monitor.

6/22/11- 0935 MD note, seen on rounds by Dr... pt requests that STD testing be cancelled. No complaints voiced will continue to monitor.

6/23/11- 1005 MD note, seen on rounds by Dr... nonverbal staff reports compliance with activities no anger outburst will continue to monitor.

6/24/11- 0930 MD note, seen on rounds per Dr... staff reports no behavioral problems. Will continue to monitor.

6/25/11- MD note, refused to talk to Dr... this AM. Continue with current treatment plan.

6/26/11- MD note, seen on rounds by Dr..., a mole on her scalp. Continue current treatment plan.

6/27/11- 0810 MD note, seen on rounds by Dr... staff reports no behavioral problems. Will continue to monitor.

6/28/11- 0910 MD note, seen on rounds by Dr... pt drowsy but awake, states," I'm okay." Drawing noted at bedside, pt appears to be using drawing as a possible coping skill will continue to monitor.

6/29/11- 1230 MD note, seen on rounds by Dr... pt awake but drowsy, no complaints voiced. Behavioral modification plan continues.

6/30/11- 0905 MD note, seen on rounds by Dr... staff reports no behavioral problems. Will continue to monitor.

7/1/11- 1430 MD note, seen on rounds by Dr... pt very calm and congenial no behavioral problems noted will continue behavioral modification plans.

7/2/11- Patient seen on rounds by Dr... asleep no distress noted, continue current treatment plan.

7/3/11 Patient seen on rounds by Dr... sleeping no distress noted. No signs/symptoms of suicidal/ homicidal ideations no auditory/ visual/hallucinations - continue current treatment plan.

7/4/11- 0950 MD note, seen on rounds by Dr... sleeping, no problems reported by staff will continue to monitor.

7/5/11- 1220 MD note, seen on rounds by Dr... pt sleeping 1:1 continues staff reports no behavioral problems will continue to monitor.

7/6/11- 1040 MD note, seen on rounds by Dr... sleeping staff reports no behavioral problems will continue to monitor.

7/7/11- 0900 MD note, seen on rounds by Dr... pt excited about going out on pass today going to Auburn for orthodontist appointment and visit with her grandmother.

7/8/11-1040 MD note, seen on rounds by Dr... sleeping- staff reports no behavioral issues will continue to monitor.

7/9/11- MD notes Pt seen on rounds by Dr... staff reports no behavior problems pt refused to talk to Dr... will monitor for behavioral changes remains on 1:1 observation.

7/10/11- MD note pt refused to see Dr... this AM staff reports she has been picking at abrasion on her arm. Remains on 1:1 observation. Monitor for behavioral changes.

7/17/11- Pt refused to speak to Dr... on rounds again today. No problems reported by staff will continue current treatment plan.

7/22/11- 1040 MD note, seen on rounds by Dr... pt states," Go, I don't want to talk to you- I'm fine." will continue to monitor.

7/23/11- 1000 MD note, pt refused to talk to Dr... this AM continues on 1:1 for safety. Continue with current treatment plan.

7/24/11-1000 MD note 1000 pt refuse to talk to Dr... this AM. States, " I want to sleep". continues with current treatment plan.

7/25/11- 0900 MD note, seen on rounds by Dr... she refuse to talk with MD state, " I'm okay." will continue to monitor

7/26/11- MD note seen on rounds by Dr... pt awake refused to talk to MD, staff reports no behavioral problems will continue to monitor.

7/27/11- MD note 1040, seen on rounds by Dr... sleeping. No behavioral problems reported by staff will continue to monitor.

7/28/11-(dated on July notes with 3/28/11)- 1005 MD note, seen on rounds by Dr... Pt sleeping refuse to speak with MD no behavioral problems reported by staff. Will continue current treatment plan.

7/29/11- 0945 MD note, seen on rounds by Dr... will not talk with MD states, " I don't like you go on." Will continue to monitor.

7/30/11- Patient seen on rounds by Dr... sleeping, no distress noted staff reports no problems continue current treatment plan.

7/31/11- Pt seen on rounds today by Dr... Pt was stating, " I want you to talk to my Dad.", became slightly louder and demanding stating, " You're keeping me here! Stop ignoring me". Remains on 1:1 observations. No behavior problems reported continue treatment plan.

8/1/11-0950 MD note, seen on rounds by Dr... refuse to talk to MD no eye contact encouraged to talk with Dr... continues to ignore, will continue monitor.

8/2/11- 0835 MD note, seen on rounds by Dr... pt requests to trim toenails, then states, " okay-bye" will continue to monitor.

8/3/11- 1100 MD note, seen on rounds by Dr... pt very talkative, laughing states, " I want Taco Bell brought up here." Very jovial, cooperative no behavior problems reported. Will continue to monitor.

8/4/11- 1100 MD note- seen on rounds by Dr... pt states" I'm good" no behavioral problems will continue to monitor.

8/5/11- 0850 MD note , seen on rounds by Dr... pt again requested to clip toenails nursing staff notified will follow up today no further needs voice will continue to monitor.

8/5/22 1300 MD note, pt seen on rounds by Dr... sleeping no distress noted, reports no problems continue 1:1 observations continue with current treatment plan.

8/7/11 Patient seen on rounds by Dr... c/o ( complained of) not having any nail clippers to clip her nails- staff trying to locate. No signs symptoms suicidal/homicidal ideations voiced, continue treatment plan.

8/8/11- 1000 MD note seen on rounds by Dr... Pt sleeping no distress noted no behavioral problems reported by staff will continue 1:1 observation.

8/9/11- 0905 MD note seen on rounds by Dr... pt observed eating breakfast continues to complain regarding toenails... to obtain clippers today...

8/10/11- 1155 MD note seen on rounds by Dr... Pt sleeping no distress noted. Staff reports she was rude and intrusive last evening and very disrespectful to staff. Continue 1:1 observation and monitoring.

8/11/11- 1025 MD note seen on rounds by Dr... Pt calm with bright affect she is very personable, denies needs at this time will continue to monitor.

8/12/11- 1155 MD note seen on rounds by Dr... cooperative and interactive with peers. Will continue to monitor.

8/13/11- MD (doctor) note 1000. Pt(patient) seen on rounds by Dr...Pt sleeping no distress noted. Remains on 1:1 observation. Continue current treatment plan, continue 1:1 observation.

8/14/11- Patient seen on rounds by Dr... Stated, " we need more Hot Pockets!" No behavior problems reported. Continue current treatment plan.

8/15/11 0805 MD note- seen on rounds by Dr... staff reports pt found a small Lego toy in the lounge and scraped arm in the bathroom, phone call with father area cleaned TAO ( topical antibiotic ointment) and dsg (dressing) applied will continue to monitor.

A review of the physician's progress notes from 6/1/2011 through 8/16/11 revealed the physician failed to document response to treatment and progress toward goals. The progress notes were written by a Registered Nurse who accompanied him on rounds and were to have been co-signed by the physician to authenticate his agreement with the information according to Employee Identifer (EI) # 1, the Chief Operations Officer.

Based on the review of medical records, Utilization Review Plan and the facility's policies and procedures, it was determined the facility failed to ensure the established goals were met and a weekly treatment team meeting to discuss discharge was held prior to discharge in 2 of 2 closed records. This affected Patient Identifier (PI) # 1 and 3 and had the potential to affect all patients served by this facility.

Findings include:

The Facility's Utilization Review Plan dated August 2, 2010

Discharge Reviews

The Utilization Review Staff will attend weekly treatment team meetings to provide current review information and evaluate discharge planning. Discharge planning begins at the time of admission and should be reflected in the physician and therapist progress notes. Discharge planning encompasses the patients' psychiatric, medical, psychosocial, vocational, family/support system, environmental, and financial needs. If the medical record reflects that the discharge indicators are met, the staff would review for a timely and appropriate discharge plan. If the patient meets the discharge indicators and is not discharged within seventy-two (72) hours, the case should be referred to the Physician Reviewer and the continued stay documented.

Facility Policy Titled: Discharge Planning and Aftercare.

Procedure:

I. Discharge Planning

1. Initial information to assist with discharge/aftercare planning will be obtained from the following sources:

...3. Nursing Assessment
2. Psychosocial Assessment
7. Psychiatric/Medical Consults

2. Additional information will be acquired from:

... 4. Progress notes
5. Treatment Team notes.

1. PI # 3 was admitted to the facility on 5/6/11 with diagnoses including Mood Disorder and Impulse Control Disorder. This patient has a history of Major Depressive Disorder,Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Relative Attachment Disorder.

Review of the physician orders dated 5/6/11 revealed orders for Thorazine 100 mg (milligram) IM (intramuscular) or PO (by mouth) as needed every 4 hours for agitation.

Review of the Medication Administration Record revealed the order for Thorazine was rewritten 5/24/11 to state Thorazine 100 mg IM every 4 hours as needed.

Review of the Treatment Plan goal dated 5/9/11 revealed a Short Term Objective of, " Pt (patient), will be free of anger and aggressive behavior. Pt. will refrain from making any homicidal threats AEB (as evidenced by) 5 consecutive days free of any outburst or aggression.

Review of the physician order revealed the patient was placed in seclusion with PRN (as needed) medication on the following dates:

5/6/11 - aggressive threatening behavior toward staff and self. Received Ativan 2 mg (milligrams) IM (intramuscular).

Patient was not put in seclusion again until 5/23/11

5/23/11 - attacked nurse. Received Thorazine 100 mg IM.

5/24/11 - aggressive and combative. Received Ativan 2 mg IM.

5/26/11 - agitated and attempted to throw a chair. Received Thorazine 100 mg IM.

5/29/11 - aggression and potentially dangerous behavior. Received Thorazine 100 mg IM.

Review of the Physician's Progress notes revealed the following:

5/20/11 at 12:40 - had just received Thorazine 100 mg for extreme agitation.

5/22/11 - Irritable

5/23/11 - irritable

5/25/11 - patient had anger outburst last night.

5/30/11 - anger outburst last night

5/31/11 - single outburst last night IM Thorazine given.

6/2/11 - Thorazine 100 mg IM yesterday.

There was no documentation the patient was free of anger and aggressive behavior for 5 consecutive days. PI # 3 failed to meet the established treatment goals and the hospital failed to follow their own policy for Discharge Planning. There was no documentation of a weekly team meeting for discharge planning.

An interview with Employee Identifier # 9, the Counselor who verified PI # 2 was not free of any outburst or aggression for 5 consecutive days.


2. PI # 1 was admitted to the facility on 10/25/10 with diagnoses including Depressive Disorder and Inhalant Abuse.

Review of the treatment plan with an entry as follows:

1. Goal # 2 was dated 10/26/11 stating the patient would process use of substance abuse (huffing) AEB discussing the use of these coping skills and implement at least 3 positive coping skills.

2. Goal # 3 was dated 10/26/11 stating the patient would exhibit a decrease in anger AEB exhibiting a decrease in aggression for 3 consecutive days, an increase in positive coping skills, and comply with medication.

3. Goal # 4 was dated 10/26/11 stating the patient would exhibit a decrease in defiant behaviors AEB complying with unit rules for 3 consecutive days.

Review of the physician's orders dated 11/16/10 revealed an order for Thorazine 50 mg PO every 4 hours as needed for anxiety/agitation.

Review of the Restraint/Seclusion Order dated 11/16/10 revealed at 13:15 the patient had an altercation with a peer. The patient was put in seclusion and give Thorazine 50 mg PO. The nurse further documented the medication had little effect on the patient and the patient continued to be loud and dramatic. The patient also refused to stay in the quiet room.

Review of the Family Session dated 11/17/10 at 06:10 revealed the therapist discussed ways to possibly implement a behavioral modification plan with the patient. The patient, mother and father agreed. There was no documentation what the behavioral modification plan was.

There was no documentation if goals # 2, 3, and 4 were met prior to discharge.

There was no documentation of a weekly team meeting for discharge planning.


PI # 1 was readmitted to the facility (PI # 2) 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse. As of 8/18/11 the patient remains at this hospital.

This condition is not met based on review of medical records and interview with administrative staff there was not an adequate number of staff available to meet the needs of all of the patients on the adolescent girls, adolescent boys and children's units 6/2/11 when an incident occurred which required all of the staff to one unit leaving two other units unattended. This had the potential to affect all patients served by this facility.

Refer to B 139.

Based on review of medical records, staffing schedules and interview with staff members it was determined:

1. The adolescent boys and children's units were left unattended 6/2/2011.

2. Patient Identifer (PI) # 2 did not receive individual therapy and or group therapy due to absence of therapist and unit restriction, this therapy was not documented as having been rescheduled.

This had the potential to affect all patients served by this facility.


Findings include:

The Child and Adolescent schedule for June 2, 2011 7 PM- 7 AM was provided to the surveyor on 8/16/11 by Employee Identifer(EI) # 2, the Director of Clinical Services. EI # 5, Registered Nurse (RN) # 2 and EI # 3, RN # 1 were assigned to work the adolescent girl and boys units and the children's unit. There were three Psychiatric Technicians (PT) assigned to work, one on each adolescent unit and 1 on the Childrens unit. Another Psychiatric Technicians provided 1:1 care to a patient on the girls adolescent unit 3:00 PM -11:00 PM, when her shift ended.

During an interview on 8/16/11 at 8:05 AM, with EI # 3 regarding an incident that occurred 6/2/11 she confirmed she was covering the girls and boys adolescent units and EI # 5 was providing the care for the patients on the Childrens unit.

EI # 5 stated that between 10:00 and 11:00 PM, the children were asleep and she was going over to the adolescent girls unit to chart; after she went out of the locked children's section into the locked adolescent boys area she heard shouting from one of the female patients and the nurse directing her to, "Stop". EI # 5 stated that she unlocked the door to the adolescent girls unit and entered to find EI # 3 behind the nurses station and a female patient, PI # 2, coming across the desk top toward the nurse. There were two PT attempting to pull the patient back off the desk top. EI # 3 stated that she was coming around the desk to help the two PTs when the patient kicked her in the lower abdomen and at that time the male PT from the adolescent boys and children side showed up and told EI # 3, " I got this."

The nurses note of EI # 3, from 6/2/11 7 PM to 7 AM shift documented, " At approximately 2205 she reported to this nurse requesting prn; when offered she demanded her father be called immediately to inform him of same."
A Restraint/ Seclusion protocol MD (physician) order form documented at 2330 the patient in child control position, team control position and team transport position was taken to the seclusion room. The restraint/seclusion flowsheet documented the patient was in seclusion from 2230-2415.

At the time of the incident a code yellow was called and the house supervisor came to the floor. He directed EI # 3 to leave the floor for a time to recover from the incident. EI # 5, the nurse responsible for the children's unit, stayed on the girls adolescent unit until EI # 3 returned (approximately 20 to 30 minutes). The nurse supervisor instructed the patient that EI # 5 would care for her the rest of the night and she would not be interacting with EI # 3 for the rest of the shift.

All of the staff members assigned to the adolescent girls, boys and children's unit were on the girls adolescent side during the incident and it is unclear the exact length of time the boys adolescent and Childrens unit were unattended by hospital staff.

The age range for the children's unit was ages 6 to 8 years old.

***

PI # 2 was admitted to the facility 1/19/11 with an Axis I diagnosis of Bipolar Disorder not otherwise specified/ Impulse Control Disorder not otherwise specified/ Polysubstance Abuse.

PI # 2 did not attend activities 6/9/11 at 3:45 PM, due to highly negative and assaultive behavior according to the documentation on the activities form.

PI # 2 did not attend group therapy on 6/10/11 because she was on unit restriction according to documentation on the group form.

PI # 2 did not participate 7/15/11 at 10:00 AM, group therapy, " Due to all female patients being on unit restriction for a 24 hour period." This information was obtained from the group form.

PI # 2 was not seen 7/20/11 due to counselor's schedule and PI # 2's visitation. This information was obtained from the progress note documented by the counselor.

PI # 2 was to seen 7/22/11 due to counselor having an appointment and workshop. This information was obtained from the progress note documented by the counselor.

PI # 2 missed her therapy sessions due to scheduling conflicts with the therapists schedule and no documentation was available to show an attempt to reschedule.