HospitalInspections.org

Based on a review of 2 open and 10 closed records, it was determined that patient #12 who was has a severe hearing deficit and is mute, had no nursing or interdisciplinary treatment team element guided interventions related to the impact of patient #12's disabilities for treatment, and no supports were offered to patient #12 to attend groups and activities.

Patient #12 was an adult who had a communication disability related to hearing and speech, and who presented via ambulance to the hospital emergency department following a demonstration of bizarre behaviors in the community. Patient #12 was subsequently involuntarily admitted to the behavioral health unit after refusing to consent to a voluntary admission. During admission, some of patient #12's behaviors indicated that he may have had some hearing ability. However, nursing note stated "Pt is hearing impaired. Pt has communicated his needs with this writer by writing." Additionally, while patient #12 was believed to be mute, a nursing note described in part, " ...Does not speak clear words and has speech impediment ..." Patient #12 communicated with physicians, and sometimes with nursing via interpreter services (signing via telecast), and at other times, by writing responses on paper.

Review of patient #12's nursing and Interdisciplinary Treatment Plans (ITP) revealed no treatment plan elements to guide treatment related to patient #12's disabilities. Review of patient #12's treatment plan revealed in part, "4. Supportive Psychotherapy, and 7. Group attendance/processing." Additional record review by the surveyor found no events of psychotherapy, and only one group attended by patient #12 during his 7-day stay.

On day 3, patient #12 was placed on 1:1 (arms-length) observation due to confusion, impulsivity and exaggerated movements without provocation. Documentation revealed that patient #12 attended group on day three of admission. There was no information on the medical record to indicate that patient #12 received interpreter services during the group. The social worker who conducted the group documented patient #12's participation in part as "Patient's mental status was elevated and anxious. Patient came to group although he has the staff under the belief that he is deaf. During group, some employees were talking outside the group room open door and patient got up and closed door as if not to hear them ...Patient was not attentive nor cooperative. Patient's body structure was slack and he was not relaxed ...Patient participated in group discussion ..."

No further information was found to quantify patient #12's lack of cooperation. It is unknown how patient #12 participated in the group discussion where no other recorded progress notes support that patient #12's verbal ability was an effective mode of communication.

While the severity of patient #12's disability was not fully known, nor fully assessed care plan guidance did not define the use of interpreter services via television or in-person during groups in order to facilitate patient #12's treatment.

On day 4 of admission, patient #12 was assessed by the physician in part, as being "calm." The 1:1 was continued on day 4 when it was demonstrated that patient #12 had an unsteady gait.

On day 5 of admission, a nursing note described, "Patient is awake, calm, alert and currently sitting in the day area ..." On this day, it was noted that the interpreting machine for American Sign Language was not working correctly. A physician and patient #12 used paper and pencil to communicate.


Additional review of patient #12's record revealed no progress note documentation of behaviors which would exclude patient #12 from group/activity participation, and no evidence that staff sought an in-person interpreter when the interpreter machine was not working. Finally, it is not documented by what authority staff excluded patient #12 from attending groups where patient #12's psychiatrist planned for him to attend groups and activities, and no psychiatrist order was found to limit his attendance.


For patient #12, the care plan failed to address the patient's communication deficits to guide active treatment for patient #12. This resulted in varying staff perceptions of patient #12's abilities, and behaviors, which directly impacted the supportive services offered to patient #12 and the ability to attend therapeutic groups and activities.