HospitalInspections.org

Based on review of policies and procedures, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the patient's right to have his or her choice physician notified promptly of his or her admission to the hospital for twenty-four of twenty-five medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR20, MR21, MR22, MR23, MR24, and MR25).


Findings include:


Review on October 15, 2016, of facility policies failed to reveal a policy to notify the patient's physician of his or her admission to the hospital.


Review on October 15, and 16, 2016, of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR20, MR21, MR22, MR23, MR24, and MR25, revealed no documented evidence the patient's physician was notified of his or her admission to the hospital.


Interview on October 16, 2016, at 10:35 AM, with EMP1 confirmed the facility did not have a policy to notify the patient's physician of his or her admission to the hospital. Further interview with EMP1 confirmed MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR20, MR21, MR22, MR23, MR24, and MR25 did not have any documented evidence that the patient's physician was notified of his or her admission to the hospital.

Based on facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure patients were allowed visitors of their own choice.


Findings include:


Review on November 15, 2016, of policy "Visitation", dated January 2016, revealed "Patients have the right to receive visitors. This right can only be limited on an individual basis by a physician for reasons of psychiatric necessity or security."


Review on November 15, 2016, of "Inpatient Treatment Program Applewood Program Handbook", no date, revealed "Visiting ... No one under the age of 18 is ever permitted on the unit."


Interview with EMP1, on November 15, 2016, at 3:34 PM, confirmed the Inpatient Treatment Program Applewood Program Handbook stated "No one under the age of 18 is ever permitted on the unit." EMP1 further confirmed the restriction did not address why the visitation restriction was reasonably or clinically necessary.

Based on review of facility policy and procedures, review of facility documents and interview with staff, it was determined the facility failed to follow their policy to include two residents of the community served by the Foundation on their interdisciplinary committee responsible for quality, safety, and risk management.


Findings include:


Review on November 15, 2016, of facility policy "Patient Safety Plan," reviewed/revised January 2016 revealed, " ... Foundation Patient Safety Improvement and Management Committee will include the patient safety officer, hospital in-house legal counsel, and identified member from the hospital's board of directors, and two residents of the community served by the Foundation.


Review on November 15 ,2016, of monthly Patient Safety Council Reports dated November 5, 2015, through November 8, 2016, revealed no documentation that two residents of the community served by the Foundation were members of the committee.


Interview with EMP3 on November 15, 2016, at 2 PM confirmed there was no documentation that two residents of the community served by the Foundation were members of the Patient Safety Improvement and Management Committee.

Based on a review of job descriptions, personnel files (PF), and staff interviews (EMP), it was determined the facility failed to designate in writing a qualified Infection Control Officer (ICO).

Findings include:

ICO job description was requested from EMP10 on November 14, 2016 at 2:26 PM. None was provided, as requested.

Review on November 14, 2016 of EMP7's "Staff Development Instructor and Support Manager" job description, dated February 14, 2016, revealed there was no documented evidence that EMP7 was designated as the ICO.

Interviews conducted on November 15, 2016, at 1:45 PM, with EMP2 and EMP7 confirmed there was no documented evidence that EMP7 was designated in writing as the ICO.

Review on November 14, 2016, of the "2016 Infection Prevention and Control Plan" revealed the plan identified an "Infection Control Preventionist" as part of the Infection Control Plan, however the facility failed to identify in writing an individual to fulfill this role.

Review on November 14, 2016 of "Infection Control Meeting Minutes" for October 3, 2016 and May 25, 2016 revealed EMP7 was present during these meetings, but was not identified as the ICO.

Based on medical record review, document review and interview, the facility failed to provide psychosocial assessments that met professional social work standards and that included an integrated summary that described anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) active sample patients (M1, M2, W1, W2, A1, A2, A3, & A4). In addition, the facility failed to follow hospital policy and procedure PC 001R, revised 10/15. This has the potential to result in a lack of professional recommended social work treatment services to be included in the treatment plan for eight (8) of eight (8) sample patients.

FINDINGS:

I. MEDICAL RECORDS:

1. Patient M1 was admitted 9/23/16 with a diagnosis of with a diagnosis of "Autism Spectrum Disorder 11" documented on the MTP [Master Treatment Plan] dated 8/22/16. The Biopsychosocial dated 8/24/16 [sic] did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning. (this patient was discharged to a general hospital for four hours and subsequently readmitted; hence the discrepancies in the dates).

2. Patient M2 admitted 9/29/16 with a diagnosis of "Disruptive Mood Regulation Disorder; Autism Spectrum Disorder Level 3" documented on the MTP dated 9/29/16. The Biopsychosocial dated 9/29/ did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

3. Patient W1 admitted 11/4/16 with a diagnosis of "Disruptive Mood Dysregulation Disorder; Autism Spectrum Disorder; Obsessive Compulsive Disorder" documented on the MTP dated 11/5/16. The Biopsychosocial dated 11/5//16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

4. Patient W2 admitted 10/25/16 with a diagnosis of "Unspecified Depressive Disorder; Post Traumatic Stress Disorder" documented on the MTP dated 10/25/16. The Biopsychosocial dated 10/27//16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

5. Patient A1 was admitted on 11/8/16 with a diagnosis of "Unspecified Anxiety Disorder" listed on the psychiatric evaluation dated 11/9/16. The Biopsychosocial dated 11/10//16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

6. Patient A2 was admitted 11/10/16 with a diagnosis of "Major Depressive D/O" listed on the psychiatric evaluation dated 11/11/16. The Biopsychosocial dated 11/11//16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

7. Patient A3 was admitted 11/8/16 with a diagnosis of "Major Depression, Recurrent, Moderate c [with] Psychotic Features" listed on the psychiatric evaluation dated 11/9/16. The Biopsychosocial dated 11/10//16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

8. . Patient A4 was admitted 11/8/16 with a diagnosis of "Bipolar Related Disorder Currently Depressed" listed on the psychiatric evaluation dated 11/9/16. The Biopsychosocial dated 11/11//16 did not contain an integrated summary that described the anticipated social work role in treatment and discharge planning.

II. DOCUMENT REVIEW

Facility policy "Policy and Procedure" PC 001R, revised 10/15 page 6 notes the following requirements for a psychosocial history: "Performed with the patient and, when possible, family members/significant others by Social Service staff within 72 hours of admission and includes complete family history, interpersonal relationships, medical/psychiatric history, ethnic /cultural and religious issues affecting treatment, abuse history, discharge planning and an integrated summary."

III. INTERVIEWS

1. In an interview on 11/15/16 at 1:15 PM, the Director of Social Work concurred with the lack of integrated summary of data in the psychosocial assessments.

2. In an interview on 11/15/16 at 3:30 PM the Director of Clinical Operations indicated improvement was needed referencing the deficient practice in the biopsychosocial assessments.

3. In an interview on 11/16/16 at 9:35 AM the Quality Assurance Director and the Clinical Director both concurred that the Biopsychosocial Histories lacked integrated summaries.

Based on record review, document review. and interview, the facility failed to identify registered nurse treatment modalities that provide a focus that addresses each patient's individual needs. There were no psychiatric nursing interventions for four (4) of eight (8) active records (Patients A1, A2, A3 and M1) and had only generic psychiatric nursing interventions for four (4) of eight (8) active records (Patients A4, M2, W1, and W2). This deficiency has the potential to result in a failure to guide treatment staff to achieve measurable, behavioral outcomes.

FINDING:

I. Record Review

1. Patient A1 (Master Treatment Plan dated 11/8/16) had no psychiatric nursing interventions for the identified problem of "Depression/Mood Instability."

2. Patient A2 (Master Treatment Plan dated 11/11/16) had no psychiatric nursing interventions for the identified problems of "Depression" and "Anxiety."

3. Patient A3 (Master Treatment Plan dated 11/1/16) had no psychiatric nursing interventions for the identified problems of "Depression" and "Anxiety."

4. Patient M1 (Master Treatment Plan dated 8/22/16) had no psychiatric nursing interventions for the identified problem of "Aggression."

5. Patient A4 (Master Treatment Plan dated 11/11/16) had the following nursing intervention for the identified problem of "Suicide Ideation."

"MHT [mental health technician] and nurses will encourage [patient] to attend therapy groups and praise [patient] for using positive coping skills." This intervention was not individualized and reflected only generic duties.

6. Patient M2 (Master Treatment Plan dated 9/29/16) had the following nursing intervention for the identified problem of "Aggression":

"Nursing staff to provide assessment and support, medication administration and education." This intervention was not individualized and reflected only generic duties.

7. Patient W1 (Master Treatment Plan dated 11/5/16) had the following nursing intervention for the identified problem of "Self Injury":

"MHT [mental health technician] and nurses will encourage [patient] to attend group therapy sessions, positively interact with peers, as well as express feelings to others." This intervention was not individualized and reflected only generic duties.

8. Patient W2 (Master Treatment Plan dated 10/25/16) had the following nursing intervention for the identified problem of "Suicidal Ideation":

"MHT [mental health technician] and nurses to provide support and encouragement for patient to attend and participate in groups, to report urges to self-harm to staff, and to utilize coping skills when needed." This intervention was not individualized and reflected only generic duties.

II. DOCUMENT REVIEW

The facility policy number PC 113 last reviewed 1/16 and titled, "Interdisciplinary Treatment Plan" stated, "The treatment plan shall contain specific interventions that relate to goals, are written in behavioral and measurable terms, and include expected achievement dates as well as the person responsible for implementation."

III. INTERVIEWS

1. On interview on 11/15/16 at 9:45 A.M., the Director of Psychology concurred that there were no nursing interventions on the Master Treatment Plan of Patient A1.

2. On interview on 11/15/16 at 12:10 P.M., RN2 and the Assistant Director of Nursing concurred that there were no RN interventions on the Master Treatment Plan of Patient A1.

3. On interview on 11/15/16 at 2:10 P.M., the Director of Nursing stated, "No, there are no nursing interventions or they are not specific to the patient."

Based on record review, document review, and interview, the facility failed to ensure that the nurse responsible for each intervention was specifically identified in three (3) of eight (8) master treatment plans (Patients M1, M2 and W2). This failure has the potential to result in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented.

FINDINGS:

I. RECORD REVIEW

1. Patient M1 (Master Treatment Plan last reviewed on 11/8/16) had no discipline or name for the staff responsible for the interventions noted on the "Behavior Support Plan" (part of the Master Treatment Plan).

a. For the identified problem of "Aggression," the interventions of "provide [patient] with simple prompts and remain out of striking distance. Move other children away from the patient who is aggressive" had no specific name identified as the responsible staff.

b. For the identified problem of "Destruction," the interventions of "Keep all rooms and unit free of debris. Remove other children from vicinity of destruction" had no specific name identified as the responsible staff.

c. For the identified problem of "Self-injury," the interventions of "Provide [patient] with one verbal prompt to stop or an alternative. Intervene if causing injury" had no specific name identified as the responsible staff.

d. For the identified problem of "Agitation," the intervention of "In a positive tone remind patient what [he/she] is working for" had no specific name identified as the responsible staff.

2. Patient M2 (Master Treatment Plan last reviewed on 11/8/16) had no discipline or name for the staff responsible for the interventions noted on the "Behavior Support Plan" (part of the Master Treatment Plan).

a. For the identified problem of "Aggression", the intervention "Patient will earn cash out for displaying appropriate behaviors and active group participation during groups" had no specific name identified as the responsible staff.

b. For the identified problem of "Self Injury", the intervention "Provide patient with high levels of social praise throughout the day when s/he is displaying appropriate behaviors" had no specific name identified as the responsible staff.

3. Patient W2 (Master Treatment Plan last reviewed on 11/10/16) had no discipline or name for the staff responsible for the interventions on the "Behavior Support Plan" (part of the Master Treatment Plan).

a. For the identified problem "Aggression", the interventions "When asking appropriately, provide patient with access to a break. Provide a timeframe of how long s/he must wait before access to preferred items/activities" had no specific name identified as the responsible staff.

b. For the identified problem "Agitation", the intervention "In a positive tone, remind patient what s/he is working for had no specific name identified as the responsible staff. "

11. DOCUMENT REVIEW

The facility policy number PC 113 titled "Interdisciplinary Treatment Plan" and last reviewed 1/16 stated, "The intervention includes the following component: Responsible Staff: The name(s) and credentials/discipline of the specific staff members responsible for the provision of the intervention."

III. INTERVIEWS

1. On 11/14/16 at 2:00 P.M. the Quality Assurance Director stated, "We consider the Behavior Support Plans a part of the Master Treatment Plan. I agree that there are no staff members assigned to implement the interventions."

2. On 11/15/16 at 1:45 P.M. RN3 stated, "I see what you mean. There are no staff members assigned to the interventions."

3. On 11/15/16 at 2:10 P.M. the Director of Nursing stated, "Yes, there are no names associated with the interventions."

Based on record review, document review, and interview, the medical director failed to:

I. Ensure the provision of psychosocial assessments that met professional social work standards, and that included an integrated summary that described anticipated social work roles in treatment and discharge planning. In addition, the facility failed to follow hospital policy and procedure PC 001R, revised 10/15. This has the potential to result in a lack of professional recommended social work treatment services to be included in the treatment plan for eight (8) of eight (8) sample patients. (See B108)

II. Ensure the identification of registered nurse treatment modalities that provide a focus that addresses each patient's individual needs. There were no psychiatric nursing interventions for four (4) of eight (8) active records (Patients A1, A2, A3 and M1) and had only generic psychiatric nursing interventions for four (4) of eight (8) active records (Patients M2, W1 and W2). This deficiency has the potential to result in a failure to guide treatment staff to achieve measurable, behavioral outcomes. (See B 122)

III. Ensure that the nurse responsible for each intervention was specifically identified in three (3) of eight (8) master treatment plans (Patients M1, M2 and W2). This failure has the potential to result in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented. (See B123)

INTERVIEW:

1. In an interview on 11/16/16 at 9:35 AM the Quality Assurance Director and the Clinical Director both concurred that the Biopsychosocial Histories lacked integrated summaries.

I. Based on record review, document review and interview, the Director of Nursing failed to ensure that Registered Nurses developed individualized psychiatric nursing interventions in the Master Treatment Plan that addressed the patient's specific identified needs. This deficiency has the potential to result in a failure to guide treatment staff to achieve measurable behavioral outcomes. (Refer to B122)

II. Based on record review, document review and interview, the Director of Nursing failed to ensure that Registered Nurses specified name and discipline for each nursing intervention in the Master Treatment Plan. This deficiency has the potential to result in the patient and other staff being unaware of which staff person was assuming responsibility for the intervention being implemented and documented. (Refer to B123)