HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that each patient's treatment plan was individualized, comprehensive and updated with changes related to the patient's goal progression for 1 (Patient #F1) of 3 sampled patients (Patient #F1-#F3) whose records were reviewed.
Findings:

Review of the hospital policy titled Individualized Treatment Plan Development Procedures revealed in part that the staff members who participate in patient care revise the treatment plan to reflect changes to the patient's clinical status, needs and/or goals.

Review of Patient #F1's medical record revealed the 13 year old patient was admitted to the psychiatric hospital on a PEC on 10/13/2023 with diagnoses including depression and oppositional defiant disorder. The patient was admitted with physician orders for routine observations every 15 minutes but the order was changed to line of sight observations at all times on 10/15/2023 at 9:27 a.m. due to the patient having aggressive behaviors.

Review of the patient's medical record revealed a note from the medical nurse practitioner dated 10/16/2023 stating that the patient possibly swallowed staples on 10/15/2023. The note further stated that the patient denied swallowing any of the staples. The provider ordered for the patient to be watched every 30 minutes for four hours and "continue to monitor patient."

On 11/06/2023 at 10:15 a.m., S1CorpRN reviewed the patient's medical record with the surveyor and confirmed there was no other documented evidence (besides the above provider's note) in the record related to the incident on 10/15/2023 when the patient was found with staples in her mouth. S1CorpRN confirmed that the patient was on ordered line of sight observations at the time that she obtained the staples.

On 11/06/2023 at 10:35 a.m., S2DON provided an incident report dated 10/15/2023 at 6:00 p.m. regarding the incident with Patient #F1. The report stated that at 5:50 p.m., it was reported by a peer that they saw the patient had staples in her mouth. The LPN brought the staples that the patient had spit out to the RN/DON to witness. Patient denies swallowing any staples. The patient states that she pulled out a few staples from a drawer while she was on the phone in the NP room and placed them in her mouth.

Review of the patient's initial treatment dated 10/13/2023 revealed problems of poor impulse control and aggressive/homicidal. Goals included: comply and take prescribed medications and ordered medical treatment, participate in therapeutic activities and assigned therapy, and decrease signs and symptoms of agitation/aggression, homicidal ideation, absence of assault, absence of dangerous impulsive acts. Interventions included: order the appropriate precaution level/reassess.
The treatment plan did not indicate the specific observation level that was ordered for the patient and was not updated with the incident on 10/15/2023 regarding the patient putting staples in her mouth. There were no new interventions noted on the treatment plan to address the incident on 10/15/2023. The patient's treatment plan was not individualized and comprehensive.

On 11/07/2023 at 10:00 a.m., S2DON reviewed Patient #F1's master treatment plan with the surveyor and confirmed it was not individualized or comprehensive and not updated with new approaches or interventions to address the incident involving staples on 10/15/2023.