HospitalInspections.org

Based on review of medical records, review of policy and procedures and interview with Employee Identifier (EI) # 3, the Nurse Manager, it was determined in 5 of 7 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) # 1, # 2, # 3, # 4 and # 8 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. PI # 1 was admitted to the children's unit 10/7/11 with a primary Axis I diagnosis of Major Depressive Disorder, Single Episode, Severe without Psychotic Features. An Axis III diagnosis of Head Lice and Burns to Right forearm.

The Master Treatment Plan was dated 10/7/11 with the following information:

Goal # 1- short term objectives-... will exhibit mood stabilization AEB (as evidenced by) no SI/HI (suicidal ideations/ homicidal ideations), no SIB (suicidal ideations behaviors), processing through family stressors and PTSD (post traumatic stess disorder), med (medication) and therapy compliance.

Interventions : 1. MD ( medical doctor) will RX( prescribe) with mood stabilizing meds to alleviate distress and see daily to evaluate response.
Target dates listed 10/21/11, 10/25/11 and 11/7/11. There was no documentation of any change being made to the interventions for Goal # 1 from 10/7/11 when it was identified through the patient's discharge 10/27/11.

Goal # 3 - short term objectives- pt (patient) will improve her impulse control AEB earning blue level 5 out of 7 days a week.

Interventions: 1. Identify impulsive behaviors, review the 'Stop light' technique, review scenarios in therapy and comply with medication management. Individual therapy (IT) 3 times a week and Group therapy (GT) 5 times a week.

Target dates listed 10/21/11, 10/25/11 and 11/7/11. There was no documentation of any change being made to the interventions for Goal # 3 from 10/7/11 when it was identified through the patient's discharge 10/27/11.

Goal # 4 - short term objectives- pt (patient) will exhibit a stable mood AEB (as evidenced by) earning blue level 5 to 7 days a week.

Interventions: 1... will develop positive coping skills, encourage venting during therapy, identify stressors and manage medication. Individual therapy 3 times a week and Group therapy 5 times a week.

Target dates listed 10/21/11, 10/25/11 and 11/7/11. There was no documentation of any change being made to the interventions for Goal # 3 from 10/7/11 when it was identified through the patient's discharge 10/27/11.

The patient was placed in time out 10/7/11, 10/9/11, 10/14/11 documented times two, 10/15/11 documented times two, 10/19/11, 10/20/11, 10/21/11 documented times two and 10/22/11 documented times 3.

Additional times outs were covered in the following documentation to show continued problems with no changes made to the interventions for the patient's care.

The 10/15/11 nurses note documented at 2:00 PM, "Returned to classroom, refusing to follow directions- given time outs x 5."

The 10/22/11 nurses note documented at 2:00 PM, " Has been placed in time out numerous times today."

Goal # 8 - short term objectives- pt (patient) will remain free of infection R/T (related to) burn on arm while receiving tx (treatment) at MVH (Mountain View Hospital) .

Interventions: 1. Nurse will monitor for S/S (signs and symptoms) of infection Q (each) shift. 2. Nurse will report any abnormal findings to MD (medical doctor) as needed. .3 Nurse will administer any treatment or medications ordered by MD, using 5 pt (point) rights.

Target dates listed 10/20/11 and 10/25/11. The 10/25/11 was marked through and resolved, well healing as of 10/21/11. There was no documentation regarding the burns, care provided or description of the burns from admission on 10/7/11 and the following nurse notes dated 10/9/11, 10/14/11, 10/15/11, 10/19/11, 10/20/11 or 10/21/11.

The treatment plan update dated 10/11/11 documented for Goal # 1- minimal progress-... continues to be somewhat impulsive, some defiance and verbal aggression noted. Increased interaction with peers.

The treatment plan update dated 10/11/11 documented for Goal # 3- minimal progress-...has earned blue level 3 days.

The treatment plan update dated 10/11/11 documented for Goal # 4- minimal progress-... does not talk during 1:1 but she will.

The treatment plan update dated 10/11/11 documented for Goal # 8- moderate progress-burn to forearm healing well.

There was no change to any of the interventions even though the patient continued to require frequent time outs to control her behaviors according to the nurse notes.

The treatment plan update was not signed by the psychiatrist or therapeutic educator on 10/11/11.

The treatment plan update dated 10/18/11 documented for Goal # 1- moderate progress-... continues to be hyper at times but slowly redirectable, no nightmares reported.

The treatment plan update dated 10/18/11 documented for Goal # 3- no progress marked-...has made blue level 4 days but her actions include NFD (not following directions), refusing assignments.

The treatment plan update dated 10/18/11 documented for Goal # 4- minimal progress- mood ... has made blue level 4 days, but has exhibited mood changes bit a peer 10/15/11..

The treatment plan update dated 10/18/11 documented for Goal # 8- marked progress- infection resolved, wound is healed with slight discoloration no S/S of infection no drainage.

There was no change to any of the interventions even though the patient continued to require frequent time outs to control her behaviors according to the nurse notes.

The treatment plan update was not signed by the psychiatrist on 10/18/11.

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 needs of this patient who continued to require time outs through 10/22/11.

2. PI # 2 was admitted to the girls adolescent unit 9/8/11 with a primary Axis I diagnosis of Major Depressive Disorder, recurrent no Psychotic Features, generalized Anxiety Disorder. On 10/4/11 a change in diagnosis was entered as Schizoaffective Disorder.

The Master Treatment Plan was dated 9/8/11 with the following information:

Goal # 1- short term objectives-... peers and staff will remain free from harm at MVH.

Interventions : 1. Conduct B and B ( belongings and body) search on admit and prn (as needed). 2. Safety checks q (every) 15 minutes and prn (as needed). 3. Pt to read and sign' No harm contract' 4. Instruct pt on +( positive) coping skills. 5. Administer meds per MD/RN (registered nurse) and monitor effectiveness. 6. Notify MD of changes.

Target dates listed 9/16/11, 9/20/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11. There was no documentation of any change being made to the interventions for Goal # 1 from 9/8/11 when it was identified through the survey date 10/28/11.

Goal # 7- short term objectives-... will attend class daily and exhibit appropriate behavior AEB earning blue level 4-5 days.

Interventions : 1. Review appropriate behavior, encourage active participation, give positive feedback.

Target dates listed 9/30/11, 10/12/11, 10/18/11 and 10/25/11.

Goal # 8- short term objectives-... will work to decrease thoughts of negative traits AEB listing positive traits.

Interventions : 1... will list daily one positive statement about herself and on a chart or journal and process with therapist IT x 3/ GT x 10 weekly.

Target dates listed 9/24/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11.

Goal # 9- short term objectives-... will verbally identify if possible the source of depressed mood AEB listing things which cause depression.

Interventions : 1. Therapist will process with ... causes of depression IT x 3 /GT x 10 weekly.

Target dates listed 9/24/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11.

Goal # 10- short term objectives-... will exhibit mood stabilization AEB no SI and decreased depression med and therapy compliance learning positive coping skills and using them when dealing with depression.


Interventions : 1. MD will RX with mood stabilizing meds to alleviate distress and see daily to evaluate response.

Target dates listed 9/24/11, 9/28/11, 10/4/11, 10/12/11, 10/18/11 and 10/25/11.

The last documented medication change on the treatment plan was 10/9/11- Depakote ER (extended release) 100 mg (milligrams) po (by mouth) now then HS (hour of sleep) starting 10/10/11. Mood swings.

The treatment plan update dated 9/13/11 documented for Goal # 1-minimal progress, continues to have SI, blocking noted with inappropriate behaviors.

The treatment plan update dated 9/13/11 documented for Goal # 7-minimal progress, participates minimally but with little motivation.

The treatment plan update dated 9/13/11 documented for Goal # 8-minimal progress, has a hard time listing positive traits.

The treatment plan update dated 9/13/11 documented for Goal # 9-moderate progress, denies being depressed.

The treatment plan update dated 9/13/11 documented for Goal # 10-no progress, continues to have SI, laughs inappropriately and minimizes behaviors.

The treatment plan update dated 9/20/11 documented for Goal # 1-minimal progress, continues to voice harmful thoughts.

The treatment plan update dated 9/20/11 documented for Goal # 7-minimal progress, seems to have little concern for education.

The treatment plan update dated 9/20/11 documented for Goal # 8-no progress, is working to decrease negative thoughts.

The treatment plan update dated 9/20/11 documented for Goal # 9-minimal progress, has discussed with her therapist her depression and included one incident of a friend committing suicide.

The treatment plan update dated 9/20/11 documented for Goal # 10-no progress, continues to have suicidal thoughts, she is now 1:1 observation for safety.

The treatment plan update dated 9/27/11 documented for Goal # 1-regression, pt still suicidal and attempts to harm self.

The treatment plan update dated 9/27/11 documented for Goal # 7-no progress, continues to have no participation.

The treatment plan update dated 9/27/11 documented for Goal # 8-regression, has not decreased her negative thoughts.

The treatment plan update dated 9/27/11 documented for Goal # 9-no progress, has listed sources of her depression but suicidal thoughts continue.

The treatment plan update dated 9/27/11 documented for Goal # 10- regression, no comments documented.

The therapist notes on the form documented, "She has attempted suicide, she continues to have SI."

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

The treatment plan update dated 10/4/11 documented for Goal # 1-regression, pt still suicidal and attempts to harm self.

The treatment plan update dated 10/4/11 documented for Goal # 7-no progress, is not attending class.

The treatment plan update dated 10/4/11 documented for Goal # 8-minimal progress, has listed some positive traits but does not reflect often.

The treatment plan update dated 10/4/11 documented for Goal # 9-no progress, has not identified every source of her depression.

The treatment plan update dated 10/4/11 documented for Goal # 10-no progress, continues suicidal with attempts- continues 1:1 for safety.

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

The treatment plan update dated 10/11/11 documented for Goal # 1-regression, pt still suicidal and attempts to harm self.

The treatment plan update dated 10/11/11 documented for Goal # 7-no progress, is not attending class.

The treatment plan update dated 10/11/11 documented for Goal # 8-regression, negative thoughts and comments continue.

The treatment plan update dated 10/11/11 documented for Goal # 9-regression, has attempted to harm herself, restrained for safety.

The treatment plan update dated 10/11/11 documented for Goal # 10-no progress, has had multiple restraints R/T SI ( related to suicidal ideations).

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

The treatment plan update dated 10/18/11 documented for Goal # 1-regression, still makes attempts to hang or choke self, continues 1:1 observation and SI thoughts.

The treatment plan update dated 10/18/11 documented for Goal # 7-no progress.

The treatment plan update dated 10/18/11 documented for Goal # 8-no progress, continues to make negative comments about herself.

The treatment plan update dated 10/18/11 documented for Goal # 9-regression, denies depression at times and she has attempted suicide requiring restraining.

The treatment plan update dated 10/18/11 documented for Goal # 10-no progress, continues with SI/HI (suicidal/homicidal) voiced- several attempts noted choking, placing head under water in sink.

The therapeutic educator and activity therapist did not sign attendance at the treatment team 10/18/11.

There was no change to interventions or treatment plan that was documented even though the patient showed no progress or regression in all of these crucial areas.

In an interview on 10/27/11 at 10:45 AM with EI # 3, nurse manager, it was confirmed that there was no documented update or change to the treatment plan interventions or goals.

3. PI # 3 was admitted to the girls adolescent unit 7/14/11 with a primary Axis I diagnosis of Bipolar Disorder not otherwise specified,
Impulse Control Disorder, and Conduct Disorder.

The Master Treatment Plan was dated 7/14/11 with the following information:

Goal # 1- short term objectives- will exhibit mood stabilization AEB decreased anger outburst no assaultive behaviors, no SI/HI/AVH (suicidal ideation/ homicidal ideation/auditory visual hallucinations), med compliance and therapy compliance.

Interventions: 1. MD will rx (prescribe) mood stabilizing meds to alleviate distress and see daily to evaluate response.

Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.


Goal # 2 - short term objectives-... will be free of any physical aggression and anger AEB 5 consecutive days free of any outburst.

Interventions : 1... and therapist will identify triggers to neg (negative) behavior and develop coping skills to deal with triggers. IT x 3; GT x 10 ( individual therapy 3 times a week and group therapy 10 times a week)


Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.

Goal # 3 - short term objectives-... will attend class daily and exhibit appropriate behavior AEB earning blue level 4/5 days.

Interventions : 1. Review appropriate behavior, encourage active participation give positive feedback.

Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.

Goal # 6 - short term objectives- pt will be free from harm while at MVH.

Interventions : 1. Search pt and belonging and remove all harmful's. 2. Give meds as ordered by MD. 3. Monitor for safety and changes in mood/ affect. 4. Give pt 1:1 when agitated to vent frustrations.

Target dates listed 7/28/11, 8/2/11, 8/9/11, 8/16/11, 8/25/11, 9/6/11, 9/16/11, 9/20/11 and 10/25/11.

The treatment plan update dated 10/4/11 documented for Goal # 1-moderate progress continues to have frequent outburst and aggression.

The treatment plan update dated 10/4/11 documented for Goal # 2-minimal progress, has exhibited improved anger aggression towards peers but has exhibited self-injurious behavior.

The treatment plan update dated 10/4/11 documented for Goal # 3-no progress, continues to be uncooperative...

The treatment plan update dated 10/4/11 documented for Goal # 6- moderate progress, pt has scratched superficial scratches on self no other problems noted.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed no progress to moderate progress 10/4/11.

The treatment plan update dated 10/11/11 documented for Goal # 1-regression,has exhibited more physical aggression- she has attacked multiple staff members in 2 days.

The treatment plan update dated 10/11/11 documented for Goal # 2-regression, has exhibited anger/aggression towards self and staff.

The treatment plan update dated 10/11/11 documented for Goal # 3-regression, continues to be uncooperative in class and is increasing aggression toward staff and peers.

The treatment plan update dated 10/11/11 documented for Goal # 6- regression, pt has made attempts to scratch self and cause self harm and has needed to be restrained.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression in each of the goals on 10/11/11.

The treatment plan update dated 10/18/11 documented for Goal # 1-minimal progress, continues to have mood swings, days of physical verbal aggression noted.

The treatment plan update dated 10/18/11 documented for Goal # 2-regression, has fought with peer and required restraints.

The treatment plan update dated 10/13/11 documented for Goal # 3-minimal progress, has had some increase in participation and has had a couple of days of improved behavior.

The treatment plan update dated 10/18/11 documented for Goal # 6- there was no documentation related to this goal.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression and minimal progress in each of the goals on 10/18/11.

4. PI # 4 was admitted to boys adolescent unit 10/3/11 with a primary Axis I diagnosis of Bipolar Disorder and Impulse Control Disorder.

The Master Treatment Plan was dated 10/4/11 with the following information:

Goal # 1- short term objectives- will exhibit mood stabilization AEB no SI/HI and decreased mood swings, no verbal/physical aggression, processing through family stressors and conflicts, med and therapy compliance.

Interventions: 1. MD will rx (prescribe) mood stabilizing meds to alleviate distress and see daily to evaluate response.

Target dates listed 10/14/11 and 10/25/11.

Goal # 2- short term objectives- will attend class daily and exhibit appropriate behavior AEB being blue level 4/5 days.

Interventions: 1. Review appropriate behavior, encourage active participation, give positive feedback.

The target date could not be read on this entry.

Goal # 3- short term objectives- will decrease anger outburst AEB remaining on blue 4/5 days

Interventions: 1. will discuss triggers for anger, anger both positive and negative coping skills, use talk therapy and comply with med management IT X 3/ GT x 10/wk.

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

Goal # 4- short term objectives- will decrease impulsive behavior AEB remaining on blue 4/5 days

Intervention: 1. will review triggers that lead to impulsive behavior positive and negative coping skill review step management technique, talk therapy and comply with med management IT X 3/ GT x 10/wk.

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

Goal # 5- short term objectives- will deny any SI AEB reporting no SI daily

Intervention : 1. will identify triggers for SI, develop safety plan use talk therapy, deep breathing techniques positive and negative coping skills IT X 3/ GT x 10/wk

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

Goal # 6- short term objectives- pt, staff, peers will be free of harm while at MVH

Intervention : 1. orient pt to staff, peers unit rules. 2. B/B (belongings/ body) search on admit and prn 3. administer meds as ordered 4. contact MD for changes in behavior, mood 5. 1:1 with pt each shift to ID (identify) and enhance coping skills 6. every 15 minute safety checks.

Target dates listed 10/12/11, 10/18/11 and 10/25/11.

The treatment plan update dated 10/4/11 documented for Goal # 1-no progress continues to be defiant, verbally aggressive.

The treatment plan update dated 10/4/11 documented for Goal # 2-no progress, has had insufficient time to fully participate.

The treatment plan update dated 10/4/11 documented for Goal # 3-no progress, will work on learning coping skills to decrease his anger

The treatment plan update dated 10/4/11 documented for Goal # 4- no progress, will work on decreasing impulsive behavior by using stop light technique.

The treatment plan update dated 10/4/11 documented for Goal # 5-no progress, will develop safety plan and work on decreasing SI.

The treatment plan update dated 10/4/11 documented for Goal # 6-no progress, staff here remain free from harm since admission.

The treatment plan update dated 10/11/11 documented for Goal # 1-no progress continues to have physical and verbal aggression, no insight, minimizing behavior.

The treatment plan update dated 10/11/11 documented for Goal # 2-regression, is mostly uncooperative and is frequently defiant and disrespectful.

The treatment plan update dated 10/11/11 documented for Goal # 3-no progress, has numerous anger outburst daily.

The treatment plan update dated 10/11/11 documented for Goal # 4- no progress- has not displayed use of positive coping skills to decrease impulses.

The treatment plan update dated 10/11/11 documented for Goal # 5-moderate progress, denies any SI.

The treatment plan update dated 10/11/11 documented for Goal # 6-minimal progress, has remained free from harm as have staff since admission.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/11/11.

The treatment plan update dated 10/18/11 documented for Goal # 1-regression, no comments were written on the form.

The treatment plan update dated 10/18/11 documented for Goal # 2-minimal progress, has frequent outbursts of profanity and threat in days but has participated in class today (10/18/11).

The treatment plan update dated 10/18/11 documented for Goal # 3-minimal progress, displays numerous outburst weekly.

The treatment plan update dated 10/18/11 documented for Goal # 4- minimal progress-displays minimal use of positive coping skills to decrease impulsive behaviors.

The treatment plan update dated 10/18/11 documented for Goal # 5-minimal progress, still has thoughts of SI with no plan.

The treatment plan update dated 10/18/11 documented for Goal # 6-no progress, pt continues to have outburst with staff and peers, pt exhibits decreased frustrations and will hit wall when angry.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/18/11.

The 10/18/11 treatment plan update was not signed by the psychiatrist.

PI # 4 was transferred to the adult unit 10/21/11 at 12:00 noon for safety due to anger control problems.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 1-regression, no comments were written on the form.

The treatment plan update dated 10/18/11 documented for Goal # 2-minimal progress, has frequent outbursts of profanity and threat in days but has participated in class today (10/18/11).

The treatment plan update dated 10/18/11 documented for Goal # 3-minimal progress, displays numerous outburst weekly.

The treatment plan update dated 10/18/11 documented for Goal # 4- minimal progress-displays minimal use of positive coping skills to decrease impulsive behaviors.

The treatment plan update dated 10/18/11 documented for Goal # 5-minimal progress, still has thoughts of SI with no plan.

The treatment plan update dated 10/18/11 documented for Goal # 6-no progress, pt continues to have outburst with staff and peers, pt exhibits decreased frustrations and will hit wall when angry.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/18/11.

The 10/18/11 treatment plan update was not signed by the psychiatrist.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 1-regression, no comments were written on the form.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 2-no progress, participates in class occasionally but has frequent outburst and aggression.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 3-minimal progress, rarely uses positive coping skills to decrease anger outburst, multiple outburst with property destruction weekly.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 4- minimal progress- impulsive rarely uses positive coping skills to decrease his impulsive behaviors.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 5-moderate progress, had thoughts of SI since last update but denies any as of yesterday.

The treatment plan update date was blank but scheduled for 10/25/11 documented for Goal # 6- no information.

There was no change to interventions, goals or treatment plan that was documented even though the patient showed regression ,no progress to moderate progress 10/25/11.

The 10/25/11 treatment plan update was not signed by the psychiatrist, therapeutic educator or staff nurse. The discharge plan was documented for 10/26/11 to discharge to another facility.

In an interview on 10/28/11 at 11:00 AM with EI # 3 regarding changes to the treatment plan. EI # 3 responsed, that they knew they needed to work on these areas. Employee Identifier # 5, Director of Clinical Services on 11/2/11 returned the following information about the updating the treatment plan. EI # 5's written response was,"No change was made to treatment plan prior to move to ICU ( adult intensive care unit). Move to ICU was change to his plan. Once on ICU his behaviors improved greatly."


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5. PI # 8 was admitted to the facility on 9/21/11 with diagnoses including Bipolar and Impulsive.

Review of the Treatment Plan dated 9/21/11 revealed Goal # 1 was for the patient to be free from harm for up to seventy-two hours prior to discharge.

Interventions include:

A. Initiate no harm contract.

B. Complete body and belonging search on admission and as needed.

C. Perform fifteen minute safety checks.

D. Administer meds as ordered.

E. Notify MD of Changes.

Review of the Team Plan Update dated 9/27/11 revealed a team review of the goals and interventions.

Review of the Restrain/Seclusion Protocol MD Order dated 9/26/11 at 4:30 PM revealed the patient began banging head on the window and on the walls.

Review of the Restrain/Seclusion Protocol MD Order dated 9/26/11 at 6:25 PM revealed the patient began banging head on the walls.

Review of the Restrain/Seclusion Protocol MD Order dated 9/27/11 at 8:25 AM revealed the patient began banging head on the walls and attempting to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 9/29/11 at 8:00 AM revealed the patient was touching the staff and peers without permission. The patient became combative and attempted to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 9/30/11 at 8:00 AM revealed the patient attempted to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 9/30/11 at 2:25 PM revealed the patient began hitting at and attempting to bite the staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/2/11 at 7:45 PM revealed the patient began banging head on the walls.

Review of the Team Plan Update dated 10/4/11 revealed a team review of the goals and interventions with only minimal progress toward goal. There was no documentation in a change in the interventions to help with the potential harm.

Review of the Restrain/Seclusion Protocol MD Order dated 10/5/11 at 8:25 PM revealed the patient began banging head on the walls and biting self.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 11:00 revealed the patient wrapped shirt around neck and attempted to bite staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 3:00 PM revealed the patient attempted to hit and bite staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 3:40 PM revealed the patient attempted to hit, kick and bite staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/6/11 at 5:20 PM revealed the patient attempted to hit and bite staff.

Review of the physician's order dated 10/6/11 at 5:30 PM revealed orders to transfer the patient to the ICU Unit.

Review of the Team Plan Update dated 10/11/11 revealed a team review of the goals and interventions with no documentation of progress toward goal. There was no documentation in a change in the interventions to help with the potential harm even though the patient was transferred to the ICU Unit.

There was no documented need for restraint/seclusion until 10/11/11. Review of the Restrain/Seclusion Protocol MD Order dated 10/11/11 at 2:35 PM revealed the patient began banging head on wall and threaten peers.

Review of the Restrain/Seclusion Protocol MD Order dated 10/14/11 at 5:15 AM revealed the patient began assaulting staff.

Review of the Restrain/Seclusion Protocol MD Order dated 10/17/11 at 11:40 AM revealed the patient head butted a staff member.

Review of the Team Plan Update dated 10/18/11 revealed a team review of the goals and interventions with no documentation of progress toward goal. There was no documentation in a change in the interventions to help with the potential harm.

The target dates on the original Treatment Plan for goal # 1 were changed from 9/28/11, 10/11/11, 10/20/11, and 10/25/11. There was no documentation the team reviewed the interventions to help improve potential harm.

An interview with EI # 4, a Nurse Manager, on 10/27/11 at 11:20 AM verified there was no documentation the team reviewed and updated the interventions.