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Tag No.: B0118
Based on reviews of the facility's policies and procedures, the medical record reviews, staff interviews, and observations, the facility failed to:
I. Develop treatment plans with all elements critical to effective Treatment Planning and implementation for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12). Specifically, (1) nursing and/or physician interventions were not present for each goal; and/or (2) the interventions were not documented as being reviewed or modified when goals were reviewed or modified. This failure results in the necessity for staff to rely on oral communication of treatment focus thus potentially prolonging patient stays.
Findings are:
A. Record Review
1. Patient A1 (master plan dated 2/25/15) had a 30-day review dated 8/13/15 when the short term goal number 4 stating, "With 2 prompts pt. will attend at least one structured recreational program weekly on 2nd shift" was added. There were no psychiatric or nursing interventions added for this goal. In addition, for each 30-day review dated 3/25/15, 4/22/15, 5/20/15, 6/4/15, 7/16/15, 8/13/15, 9/10/15, and 10/5/15 there was no documentation that interventions were renewed, revised or deleted.
2. Patient A2 (master plan dated 6/10/15) had the following 30-day reviews dated 7/08/15, 8/05/15, 9/1/15, and 9/24/15 for which there was no documentation that interventions were renewed, revised or deleted.
3. Patient A3 (master plan dated 9/16/15) had a 30-day review dated 10/13/15 for which there was no documentation that interventions were renewed, revised or deleted.
4. Patient A4 (master plan dated 9/14/15) had a 30-day review dated 10/13/15 for which there was no documentation that interventions were renewed, revised or deleted.
5. Patient A5 (master plan dated 6/10/15) had 30-day reviews dated 7/9/15, 8/6/15, 9/1/15, 9/29/15 and 10/27/15 for which there was no documentation that interventions were renewed, revised or deleted.
6. Patient A6 (master plan dated 10/28/14) had no nursing interventions for the short term goal number 2, "pt. will identify what he can do to manage a mental health relapse if it were to occur 1x weekly in groups or meetings with staff." In addition, for the 30-day reviews dated 11/25/14, 12/23/14, 1/20/15, 2/17/15, 3/17/15, 4/14/15, 5/12/15, 6/9/15, 7/7/15, 8/4/15, 9/1/15 and 9/29/15 there was no documentation that interventions were renewed, revised or deleted.
7. Patient A7 (master plan dated 12/16/14) had 30-day reviews dated 1/29/15, 2/21/15, 3/26/15, 4/21/15, 5/19/15, 6/16/15, 7/13/15, 8/11/15, 9/8/15, and 10/7/15 for which there was no documentation that interventions were renewed, revised or deleted.
8. Patient A8 (master plan dated 8/13/15) had 30-day reviews dated 9/10/15 and 10/8/15 for which there was no documentation that interventions were renewed, revised or deleted.
9. Patient A9 (master plan dated 2/12/15) had 30-day reviews dated 3/13/15, 4/12/15, 5/11/15, 6/3/15, 7/2/15, 7/31/15, 8/27/15, 9/24/15 and 10/22/15 for which there was no documentation that interventions were renewed, revised or deleted.
10. Patient A10 (master plan dated 7/8/15) had 30-day reviews dated 8/5/15, 9/2/15 and 9/30/15 for which there was no documentation that interventions were renewed, revised or deleted.
11. Patient A11 (master plan dated 7/8/15) had 30-day reviews dated 8/5/15, 9/2/15 and 9/30/15 for which there was no documentation that interventions were renewed, revised or deleted.
12. Patient A12 (master plan dated 12/16/14) had 30-day reviews dated 1/13/15, 2/10/15, 3/10/15, 4/7/15, 5/5/15, 6/2/15, 6/30/15, 7/28/15, 8/25/15, 9/22/15 and 10/20/15 for which there was no documentation that interventions were renewed, revised or deleted.
B. Interviews
1. On 10/27/15 at 11:30 a.m., the Director of Nursing stated, "No, the interventions are not noted as being revised or continued in the reviews."
2. On 10/27/15 at 2:45 p.m., RN1 stated, "The interventions are not documented as being changed or continued in the reviews."
3. On 10/27/15 at 5:40 p.m., the Chief Executive Officer stated, "Absolutely. The interventions are not addressed in the reviews."
C. Document Review
1. The facility's policy titled, "Comprehensive Treatment and Recovery Plan" (No.11-3) and dated March 2015 states, "At least every thirty days or whenever there is significant change in the individual's psychiatric/medical condition, the treatment team shall meet to discuss the progress related to the identified needs/problems, goals and objectives for the previous 30-day period and complete the Comprehensive Treatment and Recovery Plan Review. The problems, goals, objectives and interventions used must be evaluated and either continued or revised depending upon the individual's progress or lack thereof."
2. The document titled, Comprehensive Treatment/Recovery Plan Review (revised 8/2006) states under the narrative as a prompt, "This should include any modification in treatment or specific interventions being used and a statement regarding patient status."
II. Ensure that identified medical problems and treatment interventions for 12 of 12 active sample patients (A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, A11 and A12) were developed and reviewed with input from the treatment team. The medical component (Medical Treatment Plan of Care) of the master plan (Comprehensive Treatment and Recovery Plan - CTRP) allowed for treatment only by the medical physician and the nurse and was developed by the medical physician and nurse assigned to the team separate from the psychiatric component of the master plan.
In addition, the Medical Treatment Plan of Care did not enumerate treatment interventions (with duration of contact or frequency) to be provided by the medical physician. Instead, medications or special orders were listed. Although some nursing interventions (treatments) were enumerated, the frequency and duration of the interventions were not provided; other nursing treatments written in the plan were standard nursing duties or expected discipline practices, or tasks for the patient to accomplish, rather than specific modalities noted by description of the treatment to be provided, its frequency, and its duration. The Medical Treatment Plan of Care failed to document potentially useful treatment interventions from other members of the treatment team/other clinical disciplines besides Medicine and Nursing. Periodic reviews of the medical problems and treatments were inconsistently documented by both the medical physician and the nurse; and it appeared that the medical physician and the nurse reviewed the plan on different dates rather than in a collaborative review process. The medical physician did not participate in the scheduled treatment plan review meetings. These failures result in lack of clarity regarding how medical problems are to be addressed, limit coordination of medical health care delivery in the best interest of the patient, and increase the risk that medical problems will not be addressed in a comprehensive and timely manner.
Findings are:
A. Record Review
1. Medical Treatment Plan of Care (dated 2/2/15) for Patient A1 listed the physician's treatment for "blind" as "walk with white cane" and "F/U with PT. OT;" listed the physician's treatment for "constipation" as "meds (lactulose 15 ml BID; Senna with Ducosate 2 tab 8 P." listed the physician's treatment for GERD as "protonix 40 mg/day - reflux precaution." Nursing treatments were enumerated without a frequency or duration. Dates for 30-day reviews were different for the medical physician and the nurse. No measurable objectives were provided for any of the medical problems.
2. Medical Treatment Plan of Care (dated 6/2/15) for Patient A2 listed the treatment for "HTN" [hypertension] as "Titrate Lisinopril daily; check BP; check K+ Q6 mo; EKG; echo annually;" listed the treatment for "h/o etoh abuse" [history of alcohol abuse] as "check B12 level; check LFTs; AA meetings. Nursing treatments were enumerated without a frequency or duration. Dates for 30-day reviews were missing for nursing for the months of August and September. No measurable objectives were provided for any of the medical problems.
3. Medical Treatment Plan of Care (dated 9/9/15) for Patient A3 listed the physician's treatment for "DM" [diabetes mellitus] as "metformin 850 mg i tab po BID; check HgA1C; check FBS; consult ortho. pod" and listed the nursing treatment as "Labs to monitor glucose levels; consults as ordered; ensure pt compliance with ordered apt/clinic;" listed the physician's treatment for "Fe def anemia [iron deficiency anemia] as FeSO4 325 mg i tab po BID; monitor CBC" and listed the nursing treatment as "Encourage pt medication compliance; labs s ordered." There was no documentation of a 30-day review for the month of October. No measurable objectives were provided for any of the medical problems.
4. Medical Treatment Plan of Care (dated 9/14/15) for Patient A4 listed the physician's treatment for "constipation" as "Senna/ducosate 2 tabs BID; Miralax 17 gm daily; increase fluids; increase fiber" and listed nursing treatment as "Encourage increased fiber and fluids; Comply with taking senna and miralax;" and listed the physician's treatment for "obesity" as "1800 cal; 8 oz O.J.; increase physical exercise" with the nursing treatment listed as "encourage Pt to follow diet plan and exercise." No measurable objectives were provided for an of the medical problems.
5. Medical Treatment Plan of Care (dated 1/29/15) for Patient A5 listed the physician's treatment for "obesity" as "diet/exercise/healthy [illegible]" and the nursing treatment of "provide Education on the benefits of weight loss" did not include a duration or frequency of contact; the physician's treatment for "HTN" (hypertension) was illegible and the nursing treatment was listed as "administer medication as ordered; monitor BP; provide Medication Education on benefits and side effects" without a documented frequency or duration for this intervention. No measurable objectives were provided for any of the medical problems.
6. Medical Treatment Plan of Care (dated 1/20/15) for Patient A6 listed the physician treatment for "DJD" [degenerative joint disease] as "Oscal 500 mg daily; Tylenol prn and the nursing treatment as "administer medication as needed; Provide Medication Education on benefits and side effects" without a frequency or duration; listed the physician treatment for "Poor oral hygiene" as "Dental F/U; Dental Care" with a nursing treatment of "monitor pt for pain (oral); provide Education on the benefits of good oral hygiene" without notation of frequency or duration. Physician and Nursing review dates were different for each monthly review. No measurable objectives were provided for any of the medical problems.
7. Medical Treatment of Care (dated 10/14/15) for Patient A7 listed the physician treatment for "hyperlipidemia" as "meds; low fat diet; check lipid profile" with nursing treatment as "(1) Adm meds per order; (2) compliance with diet; (3) Encourage to attend labs and report abnl labs to MD promptly;" listed the physician's treatment for "constipation" as "meds...increase H2O...increase fiber; Mag Citrate for Severe Constipation" with nursing treatments listed as "(1) adm meds per order; (2) Encourage to drink plenty of H2O; (3) increase fiber in diet & monitor bowel movement;" listed the physician's treatment for "Dysphagia" as "Swallowing Eval; complete diet downgrade" with nursing treatments listed as "1:1 observation at meals to prevent choking" and "compliance with dysphagia diet - no bread at all 3 meals;" and listed the physician's treatment for "Seizure D/O s/p craniotomy" as "meds; tx symptomatically; neuro prn" with nursing treatment listed as "(1) Adm meds per order; (2) Attend neuro clinic prn." Documentation of monthly nursing reviews was missing for the months of January, February, April, May, June, July, August, and September. No measurable objectives were provided for any of the medical problems.
8. Medical Treatment Plans of Care (dated 8/6/15 and 9/14/15) for Patient A8 listed the physician's treatment for "HTN" [hypertension] as "no meds; monitor BP monthly" with the nursing treatment as "The patient will be monitored as needed and will [illegible] Bloodwork;" listed the physician's treatment for "hx of anemia" as "check CBC with diff" with the nursing treatment as "medication will be supplied for the patient as ordered;" listed the treatment for "constipation" as "Colace 100 mg BID; increase fluids/exercise" with the nursing treatment as "The patient will be encouraged to drink fluids, adhere to diet and take both PRN and routine medication for constipation." No measurable objectives were provided for any of the medical problems.
9. Medical Treatment Plan of Care (dated 4/9/15) for Patient A9 listed the physician's treatment for "HTN" [hypertension] as "meds...check BP/Pulse; low sodium diet; EKG; Echo; Cardio PRN" with nursing treatment as "routine lab work will be drawn...the patient's blood pressure and pulse rate will be monitored as per orders...The Patient will be encouraged to stick to ordered diet;" and listed the physician's treatment for "Nocturnal enuresis" as "Vessicare; UA; ref Urology prn" and listed the nursing treatment as "order Urinalysis will be completed as ordered; Urology appointment will be scheduled for the patient." Physician reviews were not documented for the months of June, July, August, September, or October. No measurable objectives were provided for any of the medical problems.
10. Medical Treatment Plan of Care (dated 7/2/15) for Patient A10 listed the physician's treatment for "hypo Vit D" [vitamin D deficiency] as "Vit D replacement; Vit D levels" with nursing treatment listed as "nurse will document medication as ordered. Nurse will provide on-going medication education;" listed the physician's treatment for "hypothyroidism" as "meds; TFT's" with nursing treatment listed as "Nurse will administer meds as ordered. Encourage compliance with all ordered lab work. Provide on-going health care education for hypothyroidism;" and listed the physician's treatment for "tuberous sclerosis" as "tx symptomatically" with nursing treatment listed as "Encourage cooperation with all ordered labs & diagnostic tests. Provide on-going health care education." No measurable objectives were provided for any of the medical problems.
11. Medical Treatment Plans of Care (dated 6/20/15, 9/8/15, and 10/3/15) for Patient A11 listed the physician's treatment for "r/o HTN" [rule out hypertension] as "monitor BP; decrease Na+; EKG; Echo" with nursing treatment listed as "FRN will monitor [name of patient]'s BP as ordered; FRN will provide health care educations on all ordered tests to promote compliance. FRN will monitor diet for compliance;" listed the physician's treatment for "Hep C+" [hepatitis C] as "check viral load; check áfetoprotein; check Hepatic U/S [ultrasound]- pt refuses W/U" with nursing treatment listed as "educate pt about Hep C and effects on body; encourage pt to comply with lab work; educate pt on importance of complying with U/S;" listed the physician's treatment for "mass left kidney" as "pt refusing f/u recommendation of CT with contrast; psych aware; Pt agrees to CT scan without contrast - referral written 9/1/15" with nursing treatment listed as "Provide health education regarding name, purpose, etc of ordered diagnostic tests. Provide education on possible benefits of compliance & possible hazards of non-compliance;" and listed the physician's treatment for "Left inguinal hernia" as "Stable; refuses further eval & tx;" with nursing treatment listed as "Nurse will provide on-going health care education & encourage cooperation with all ordered diagnostic tests & evaluations." No measurable objectives were provided for any of the medical problems.
12. Medical Treatment Plan of Care (dated 4/7/15) for Patient A12 listed the physician's treatment for "HTN" [hypertension] as "Norvasc 5 [illegible]; low Na diet" with nursing treatment listed as "administer Norvasc as prescribed; encourage compliance with low sodium diet; provide education on HTN; monitor BP monthly, & as clinically indicated;" listed the physician's treatment for "DM" [diabetes mellitus] as "1800 cal ADA diet; Lantus [illegible]; Acucheck [sic] Daily; check HgA1C" with nursing treatment as "administer insulin as prescribed; perform accucheck as prescribed; and PRN as clinically indicated; encourage compliance with lab work for HgA1C monitoring; provide education on diabetes; perform skin assessment monthly" without a documented frequency or duration for the interventions. No measurable objectives were provided for any of the medical problems. Physician and Nursing reviews were not documented for the months of September and October.
B. Interviews
1. In an interview with the Chief of Medicine on 10/27/15 at 10:15 a.m., he agreed that the Medial Treatment Plans not delineate problems with objectives and that "treatment" items were not interventions to be provided by the doctor. He agreed that many of the plans "listed medications to be administered or labs to be obtained or consultation/referrals to be made." He also acknowledged that there were no notes by the physician describing the interventions provided and the progress made in addressing the noted problems. He indicated that he was engaged in a process of revamping the documentation for medical services.
2. In an interview with the Chief Medical Officer (Medical Director) on 10/27/15 at 4:40 p.m., she indicated that the Medical Treatment Plans did not provide documentation on measurable objectives, interventions with frequency and duration, or a review process with input from other team members. She acknowledged that the medical physicians did not participate in the 30-day treatment plan reviews - "they do not attend." .
C. Observation
1. In the Treatment Planning Meeting for Patient A5, observed on 10/2715 at 10:55 a.m. in the presence of the Chief Medical Officer (Medical Director), there was no review of the patient's medical problems.
D. Document Review
1. The facility's policy titled, "Comprehensive Treatment and Recovery Plan" (No.11-3) and dated March 2015 states, "At least every thirty days or whenever there is significant change in the individual's psychiatric/medical condition, the treatment team shall meet to discuss the progress related to the identified needs/problems, goals and objectives for the previous 30-day period and complete the Comprehensive Treatment and Recovery Plan Review. The problems, goals, objectives and interventions used must be evaluated and either continued or revised depending upon the individual's progress or lack thereof." The policy also states that the Medical Treatment Plan of Care is a component of the "Comprehensive Treatment and Recovery Plan."
Tag No.: B0125
Based on reviews of the facility's policies and procedures, medical record reviews, patient and staff interviews and observations, the facility failed to:
I. Ensure that patients on the Civil Program units and Regional Forensic Psychiatric Center (RFPC) units received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on evenings and weekends. On evenings and weekends, no therapeutic groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge.
Findings are:
A. Document Review
Review of the document "Treatment Schedule" for the inpatient units 1A1, 1C1, 10A1, 10A2, 10C1, 51A1, 51A2, 51B1, 51B2, 51C1, and 51C2 revealed that activities for Saturday and Sunday each week were labeled "Leisure Activities" and consisted of "Ping Pong, Music Board Games, Floor Games, Exercise/Fitness and Computers." There were no therapeutic groups/activities listed.
B. Interviews
1. On 10/26/15 at 1:00 p.m., Patient A2 stated, "There is nothing to do on the weekends."
2. On 10/26/15 at 1:20 p.m., Patient A8 stated, "The weekends are so boring. I dread the weekends here."
3. On 10/27/15 at 2:35 p.m., in response to a question regarding the provision of therapeutic activities on weekends, Patient A6 stated "Not really. Weekends are for 'down-time.' They have some activities but not treatment."
4. On 10/27/15 at 1:20 p.m., the Director of Rehabilitation Services stated, "No, we do not have therapeutic groups on the weekends. We are in the process of hiring more staff for that."
5. On 10/27/15 at 11:30 a.m., the Director of Nursing stated, "No, there are only leisure activities on the weekends."
6. On 10/27/15 at 4:40 p.m., the Medical Director acknowledged that, although leisure activities were provided, "the hospital does not provide therapeutic activities on the weekends."
II. Appropriately utilize and document restraints as external controls of violence with failure to
ensure that use of mechanical wrist-to-waist restraints was based on an immediate threat of harm to self/others for all patients in the Regional Forensic Psychiatric Center (RFPC) units. Patients were placed in wrist to waist restraints and escorted by facility nursing staff without documented justification during transportation out of the facility for medical care or legal matters. This practice results in a failure of patients' right to be free of restraint without justification that restraint is used for imminent risk of danger to self and/or others and appropriate assessment and monitoring.
Findings are:
A. Interviews
1. During an interview with the DON on 10/27/15 at 11:45 a.m., she acknowledged that mechanical restraints were applied to all patients in the RFPC Units who were transported out of the facility. She acknowledged that no specific physician orders, assessments or monitoring by nursing or physician staff were documented for these patients in mechanical restraints.
2. During an interview with the Medical Director on 10/27/15 at 2:10 p.m., she acknowledged that forensic patients were placed in mechanical restraints when taken out of the facility by policy without a specific physician order, behavioral justification, or documented monitoring and assessment by nursing or physician staff.
3. During an interview with MHT 2, a Forensic Security Technician on 10/27/15 at 2:15 p.m., he stated, "We move forensic patients out of the facility in cuffs and shackles. We do not need a doctor's order. We do not do monitoring documentation either."
B. Document Review
1. The Office of Mental Health and Substance Abuse Policy, number SMH-P-12-02, dated 4/04/12 presented by the facility as current policy, stated the following: "When RFPC patients must be transported outside the secure perimeter for medical services, transport and custody are the RFPC's responsibility with the following procedures mandated: Mechanical restraints, made of either metal or leather, shall be employed to maintain care, custody and control of forensic clients whenever an RFPC patient is transported and escorted outside the secure perimeter by hospital staff. For the purpose of total evacuation, flex cuffs may be employed rather than metal or leather. A physician's order is not needed when restraints are used for custody purposes."
2. The RFPC Policy and Procedures Manual, titled Outside Hospital Duty-Transportation, Custody, and Treatment, reviewed 2/24/11, presented by facility as current policy, stated the following "Patients must be cuffed with metal restraints when being transported to any outside hospital or treatment facility."
3. The RFPC Policy and Procedures Manual, titled Flex Cuff Policy, reviewed 2/24/11, presented by facility as current policy, stated the following "Plastic cuffs are a transport device that do not require a physician's order and are to be used only for the duration of the test, or mass transport."