HospitalInspections.org

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Based on record review and interview in one (1) of five (5) records reviewed, a Physician did not accurately document a patient's treatment in the Medical Record (Patient #5).

This failure resulted in the Medical Record containing conflicting information regarding the patient's Plan of Care.

Findings:

A review of Patient #5's Psychiatric Nursing Admission History and Assessment dated 05/27/16 at 3:00PM documented that this 14-year-old female has a chief complaint of being suicidal as she states that she feels worthless. The Section titled "Prescribed and over the counter medications taken at home" documents that the patient is not on any medication.

The Medication Reconciliation Admission Order Form dated 05/27/16 at 5:40PM documented that the patient had no allergies and "None" was written under the list of medications.

A review of the Psychiatry Note dated 05/31/16 at 9:10AM documented that the patient was "Pending consent for psychotropic medication support".

A review of the Psychiatry Notes dated 06/02/16, 06/03/16, 06/06/16, 06/07/16 and 06/08/16 documented that the patient was "Still pending informed consent for medication management".

During an interview with Staff H (Physician) and Staff J (Chief Quality Officer) on 06/14/16 at 2:00PM, the staff members explained that the terminology of "Pending informed consent from Administration for Children's Services infers that the parent has to give consent for the child to receive psychotropic medications. In this case the facility was still waiting for permission to start the child on a medication regime."

However, a review of Patient #5's Psychiatric Progress Note on 05/28/16 at 11:35AM inaccurately documented that "The patient is taking psychotropic medication support for depression and possible PTSD (Post Traumatic Stress Disorder)."

A review of the Psychiatry Note on 06/09/16 at 9:10AM stated that the patient was "Less irritable, angry and tenuous. Tolerating medications well." "Pending informed consent from ACS (Administration for Children's Services)."

The Psychiatry Note on 06/10/16 at 8:58AM stated that the patient was "Less irritable, angry and tenuous. Tolerating medications well." "Still pending approval from ACS for the medication regime."

The Medication Administration Record for the period dated 05/27/16 through 06/14/16 documented that "No Meds ordered at this time." (With the exception of a Depo Provera injection on 06/06/16 and Zithromax X 1 stat on 06/03/16).

The facility's Policy titled "Guidelines for Completing Progress Notes" dated 04/2016, documented that a "Timely, accurate record shall be maintained for each Brunswick Hall patient reflecting the patient's condition, the treatment provided, and the patient's response to that treatment."

During an interview with Staff H on 06/14/16 at 10:30AM, the staff member stated that the patient was not on psychotropic drugs yet as the facility did not yet have informed consent from ACS. He states that he made a mistake in documenting that the patient tolerated the medications well.
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Based on observation and staff interview, the facility failed to ensure that all floor and wall finishes of the facility's buildings were maintained in good repair.

Findings:

On 06/14/16 at 2:00PM, it was observed that an approximately 4" (four inch) by 3" (three inch) portion of a floor tile in Patient Room 201 in the Carlin Building was in disrepair (e.g., chipped / pitted surfaces).

On 06/14/16 at 2:15PM, it was observed that a portion of the cove base along a floor-wall juncture in Patient Room 109 in the Carlin Building was in a state of disrepair (e.g., cove base peeling off the wall).

On 06/14/16 at 2:20PM, it was observed that an approximately 12" (twelve inch) by 4" (four inch) cove base along a floor / wall juncture in Patient Room 107 in the Carlin Building was in disrepair because it has peeled off the wall and was missing.

As per interviews with Staff W (Director of Environmental Services) on 06/14/16 at 2:15PM and 2:20PM respectively, the staff member confirmed these findings and said he will inform the facility Administrator.
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Based on observation and staff interview, the facility failed to ensure that kitchen equipment was maintained in good repair.

Findings:

On 06/15/16 at 10:50AM, it was observed that there was an approximately 1/8" (one-eighth inch) to 1/2" (one-half inch) wide crevice (an unsealed opening) between where the food preparation sink inside the Kitchen of the Brunswick Hall Building was attached to the wall in this room. The crevice could potentially provide a harborage area for vermin such as roaches and is not an easily cleanable surface.

As per concurrent interview with Staff W (Director of Environmental Services), the staff member confirmed this finding and said he will inform the facility Administrator.
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Based on document review, observation and interview, the facility did not ensure that: (A) the glucose testing practice was consistent with the facility's Policies and Procedures in three (3) of three (3) observations, and (B) personnel had readily-accessible alcohol-based hand rubs.

These failures place patients and staff at increased risk for infections.

Findings pertinent to (A) above include:

The facility's Policy and Procedure titled "Glucometer: Use of Abbott Precision Xceed Pro Blood Glucose Meter ..." last revised March 2016 directed staff to "Have patient wash hands with soap and warm water ..." prior to testing patient's blood glucose levels. The use of alcohol for skin cleansing was not stated in the Policy.

The facility's "Annual Blood Glucose Meter Competency" Checklist states "Nurse instructs patient to cleanse hand with soap and water, or uses an alcohol prep ...".

During an observation of Staff N (Licensed Practical Nurse) on 06/14/16 at 11:06AM, Staff N did not direct Patient #12 to wash their hands prior to having their blood glucose test performed. The same lack of patient handwashing prior to blood glucose testing was observed on 06/14/16 at 11:40AM with Staff O (LPN) and Patient #13, and on 06/15/16 at 11:18AM with Staff D (LPN) and Patient #12. In all of these observations, alcohol was used to cleanse the skin. This was acknowledged by Staff S (Nurse Manager) on 06/15/16 at 11:30AM, who stated "Staff use alcohol to wipe down the patient's finger".

These findings were discussed with Staff A (Chief Nursing Officer) and Staff J (Chief Quality Officer) on 06/15/16 at 3:00PM. Interview with both Staff S and Staff J confirmed the inconsistency between the current Glucometer Testing Policy, Annual Competency Evaluation and practice.

Findings pertinent to (B) above include:

The facility's Policy & Procedure titled "General Infection Control Guidelines" last revised January 2016 stated that "Personnel will be provided with individual personal-sized bottles of alcohol based sanitizers which can be refilled in the Nursing Stations ... ".

Observations in the facility's ADW (Adult West) and ADE (Adult East) Inpatient Units during tours between 06/13/16 and 06/15/16 identified staff unlocking the Nursing Station Office door and entering the Nursing Station to utilize the hand sanitizer bottle dispenser.

An interview with Staff Q (Aide) on 06/15/16 at 12:10PM revealed that staff do not usually keep hand sanitizer on their person, and if sanitizer is needed, staff will have to walk to the locked Nursing Station Office and unlock the door with a key to access it. This was confirmed with Staff S (Nurse Manager) who stated "I cannot recall if the Policy & Procedure asks the staff to keep gloves or sanitizer on them, but I encourage them to have it".

These findings were discussed with Staff A (Chief Nursing Officer) and Staff J (Chief Quality Officer) on 06/15/16 at 3:00PM. Staff J explained that the personal-sized hand sanitizers are provided to employees if they ask for it. Staff A stated "They don't always carry it or have it on them".

Based on medical record review and staff interview it was determined that the Psychosocial Assessment of six (6) of eight (8) active sample patients (A2, A20, B5, C4, C13 and D2)
failed to describe the efforts or role the social work staff would be pursuing in discharge planning. This failure results in no information for the other members of the multidisciplinary treatment team as they consider the Treatment Plan.

Findings include:

A. Medical Record Review:
The Psychosocial Assessments of the following patients (dates in parenthesis) A2 (6/01/2016), A20 (6/10/2016), B5 (5/13/2016), C4 (5/31/2016), C13 (6/08/2016) and D2 (6/02/2016) all lacked any description of the anticipated role of the social work staff.

B. Staff Interview:

On 6 14/2016 at 12:00 PM the Director of the Department of Social Work was interviewed. She was shown the Psychosocial Assessments of the patients described in Section I., above. After reviewing them she concurred that this information was lacking.

Based on medical record review and staff interview it was determined that for seven (7) of eight (8) active sample patients (A2, A20, C4, C13, D2, E2 and F4), the assessment of memory functioning in the mental status examination failed to describe the data that led to conclusions described as "intact". This failure results in no information that might be useful in future examinations that would support if memory functioning had changed over time.

Findings include:

A. Medical Record Review:

1. Patient A2: The Psychiatric Evaluation dated 6/02/2016 stated for the examination of memory functioning "Recent and remote memory appears to be intact."

2. Patient A20: The Psychiatric Evaluation dated 6/10/2016 stated for the examination of memory functioning "Recent and remote memory appears to be intact."

3. Patient C4: The Psychiatric Evaluation dated 5/29/2016 stated for the examination of memory functioning "Memory, cognition is intact."

4. Patient C13: The Psychiatric Evaluation dated 6/10/2016 stated for the examination of memory functioning "Recent and remote memory appears to be intact."

5. Patient D2: The Psychiatric Evaluation dated 6/02/2016 stated for the examination of memory only "Short term memory is fair."

6. Patient E2: The Psychiatric Evaluation dated 4/21/2016 stated for the examination of memory functioning "Short term memory is fair."

7. Patient F4: The Psychiatric Evaluation dated 5/26/2016 lacked any information about immediate, recent and remote memory functioning.

B. Staff Interview:

On 6/15/2016 at 10:00 AM the clinical director was interviewed. He was shown the findings described in Section I, above. After reviewing them he agreed that "intact" does not differentiate memory functioning in various spheres such as immediate, recent or remote and does not provide information or data as to how these assessments were determined.

Based on interview and record review the facility failed to develop and document comprehensive treatment plans based on the individual needs of eight (8) of eight (8) active sample patients (A2, A20, B5, C4, C13, D2, E2 and F4). Treatment plans for each patient were chosen from pre-printed forms. Many of the interventions were listed as generic role functions. For all active sample patients there were no additions or changes based on individual patient findings. This failure resulted in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings.

Findings include:

A. Review of Treatment Plans:

Review of treatment plans revealed that for eight (8) of eight (8) active sample patients (treatment plan dates in parenthesis): A2 (6/1/16); A20 (6/10/16); B5 (5/12/16); C4 (6/8/16); C13 (5/31/16); D2 (6/2/16); E2 (4/21/16 with review date of 6/6/16); and F4 (5/26/16 with review date of 6/13/16), there was failure to document individualized patient goals and specific modalities/interventions based on the patient's needs. Treatment plans for each patient were based on pre-printed forms for identified problems (e.g. depression, psychosis, destructive behavior, suicidality, mood instability, thought disorder). The treatment plans were initiated by nursing soon after admission and completed by social work. The majority of long-term and short-term goal(s) listed were the same for all patients with all long-term goals being non-measurable. For the majority of all identified problems, all interventions for clinical disciplines were identified as acceptable for all patients with the selected problem(s). Many of the interventions were listed as generic role functions. For all active sample patients there were no additions or changes based on individual patient findings.

B. Interview:

1. During interview on 6/14/16 at approximately 11:30 a.m. with review of treatment plans, the Assistant CEO/psychiatrist stated that the goals and interventions on the treatment plans needed to be individualized.

2. During interview on 6/14/16 at 1:50 p.m. with review of treatment plans, the DON agreed that the nursing interventions needed to be more individualized.

3. During interview on 6/15/16 at 10:00 a.m., physician interventions on the treatment plans were discussed. The Clinical Director acknowledged that the interventions were generic.

Based on medical record review and staff interview it was determined that the clinical director failed to ensure that:

I. Psychosocial Assessments contained information as to what the role of the social service staff would be in discharge planning. (Refer to B108)

II. Psychiatric Evaluations included an adequate assessment of memory functioning rather than only stating "intact". (Refer to B116)

III. Treatment Plans were individualized and that they were not a listing of discipline specific tasks as interventions. (Refer to B118)

Based on observation, interview and document review the Director of Nursing failed to:

I. Ensure that nursing interventions on the treatment plans were individualized based on patient needs. Many of the interventions were listed as generic role functions. For all active sample patients there were no additional nursing interventions or changes in the pre-printed forms based on individual patient findings. This failure resulted in absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings. (Refer to B118)

II. Ensure that monitoring and documentation of safety observations and patient off-unit movement for various treatment/functions for patients on 1 of 6 units (Legacy) were
documented properly and in a timely manner. On 6/13/16 there was failure on the part of two mental health technicians (MHTs) to properly document three 15-minute safety checks for nine (9) of 19 patients and to accurately document the movement of patients when leaving the unit. These events resulted in a safety risk for all patients on this unit.

Findings include:

A. Observation of the 15-minute monitoring sheet for nine (9) of 19 patients on the Legacy Unit (adult males) on 6/13/16 at 2:00 p.m. revealed that safety monitoring for three (3) 15-minute (1:15, 1:30 and 1:45 p.m.) monitoring checks for these 9 patients had not been documented. When MHT I (Mental Health Technician 1) was asked about failure to document the patient monitoring checks in the time the patients were observed, she stated that she would document all the safety checks at one time.

B. Upon review of the monitoring sheet for these patients with RN 3 on 6/13/16 at 2:05 p.m., RN 3 verified the findings as documented in A. above. When asked how the safety checks on the patients who were taken off unit to the game room would be documented and if their monitoring sheets were with the personnel in the game room, RN3 reported that the MHTs on the ward had all monitoring sheets and the aides with the patients off-unit would "give input to the staff member on the ward who are responsible for the monitoring sheets upon return of the patients to the unit."

C. During the 6/13/16 interview at 2:05 p.m. the surveyor requested a list of patients who were on the unit and those who had been taken off the unit from RN 3. The surveyor was referred to MHT 1 for this information. When MHT1 was asked for a list of the patients who were taken off-unit to the game room, MHT1 showed the surveyor a list of all of the patients (19) assigned to the ward at that time stating, "I haven ' t listed those yet." When asked how that would be done now, MHT1 stated, "I don ' t have any trouble remembering who they (patients) are." At this time MHT1 placed a check by the names of eight (8) of the 19 patients assigned to the unit who were in the off-unit game room.

D. Observation of the patients from the Legacy Unit in the off-unit game room on 6/13/16 at 2:10 p.m. revealed nine (9) patients, rather than eight (8) patients as identified by MHT 1. A list shown to the surveyor by MHT 3 in the game room revealed a list of 10 patients in the game room including one non-sample patient (Patient C12) who MHT3 told the surveyor that this patient was upstairs on the unit. MHT 3 stated that his/her name had not been removed from the off-unit list. Patient C12 was interviewed in his/her assigned bedroom at 2:20 p.m. on the Legacy Unit. Patient C12 stated that s/he decided not to go to the game room.

E. During the interview on 6/13/16 at 2:25 p.m., this surveyor reviewed the above findings (listed in A, B, C, and D) with RN 4 who verified that there was a discrepancy in the off-unit patient list completed by MHT 1 and the list held by MHT 3 in the game room. She reported that there was no policy stating that safety monitoring checks would be documented upon a patient(s) return to the ward based on another MHT's verification of safety while off the ward.

F. Comparison of the list of patients who were off-unit in the game room by MHT 1 and the list of patients actually in the game room provided by MHT 3 revealed that non-sample Patient C12 was in his/her bedroom rather than in the game room as shown by MHT 3's lists. In addition, non-sample Patients C7, C8 and C14 who were reported to be on the unit by MHT1 were in the off-unit game room and non-sample Patients C6 and C11 who were reported to be downstairs in the game room were on the unit.

G. During interview on 6/14/16 at 1:50 p.m., this surveyor reviewed the safety monitoring findings with the Director of Nursing. The Director of Nursing verified the findings related to failure to document the 15-minute monitoring checks, stating "for patient safety, staff should know where patients are at all times".

H. During interview on 6/15/16 at 10:30 a.m. the Director of Nursing was attempting to verify which patients were taken off-unit to the game room and which patients remained on the Legacy Unit during the incident on 6/13/16. She reported that staff did not all agree on which patients were taken off-unit. The Director of Nursing also verified that current nursing policy does not address the procedure for timely and correct documentation of the 15-minute safety checks nor patient movement when going off-unit.