HospitalInspections.org

Based on review of the Adult Unit emergency logs and interview with supervisory staff, it was determined the facility failed to assure the readiness of the facility's emergency equipment.

This affected 1 of 1 Adult Unit Rapid Response Bag and had the potential to affect all patients receiving care at this facility.

Findings include:

During the tour of the Adult Unit on 2/13/18 at 10:00 AM with Employee Identifier (EI) # 4, Nurse Manager, Adult Unit, the emergency equipment logs were reviewed. EI # 4 stated the equipment was to be checked daily on night shift.

Review of the January and February logs revealed no documentation the equipment was checked for the dates of 1/21/18, 1/27/18, 1/29/18, 1/30/18, 2/3/18, 2/11/18 and 2/12/18.

An interview was conducted on 2/15/18 at 11:40 AM with EI # 4 who confirmed the staff failed to check emergency equipment daily.

Based on observations, review of facility policies, Acute Services Daily Checklist documentation and staff interviews, it was determined the hospital staff failed to ensure:

1) The adolescent boys unit was free of ligature risks.

2) All patients were treated with respect and dignity by all staff.

This had the potential to affect all patients treated at the facility.

Findings include:

Policy: Safety Checks
Revision Date: 01/18

I. Policy

All Units-Adult...Adolescent...will do safety checks every shift.

...to ensure a safe environment for all patients and staff...

III. Procedure

1. Unit nursing staff will assess each patient room and public areas for...

b. Hazardous items...

d. Any unit maintenance will be noted and reported to maintenance...

Policy: Patient Bill of Rights
Revision Date: 02/11

I. Policy

It shall be the policy...that all staff members shall support and protect the fundamental human, constitutional, and statutory rights of each patient...

II. Fundamental Rights

A. To be treated with dignity and respect on an individual basis in a consistently humane fashion, and with the utmost professional care...

1. During observations on the adolescent boys unit on 2/13/18 from 9:40 AM to 12:30 PM with Employee Identifier (EI) # 11, Nurse Manager Residential Treatment unit, the surveyor observed three (3) patient showers with standard faucets (would bear weight) which is a ligature risk. The standard shower faucets were located in patient room 211 and 2 common restrooms directly across from the day room lobby.

Review of the Acute Services Daily Checklist for unit safety rounds documentation dated 2/12/18 and 2/13/18 revealed staff failed to identify and initiate corrective action for 3 shower faucets.

2. At 11:40 AM, EI # 9 Environmental Services employee was cleaning on the adolescent boys unit in the dayroom area.

The surveyor, sitting in the enclosed nurse station, observed and overheard EI # 9 repeat 3 times with raised voice, smiling and laughing, "I want my prn (as needed) [medication], I want my prn, I want my prn."

At the time of EI # 9's comments, there were several adolescent boys sitting in the dayroom and 2 Mental Health Technicians who witnessed EI # 9's disrespectful behavior.

At 12:10 PM, EI # 9 was cleaning in the nurse station. The surveyor interviewed EI # 9 who replied, "you heard me?" EI # 9 failed to ensure all patients were treated with respect and dignity.

In an interview on 2/15/18 at 11:30 AM, EI # 1, Assistant Director of Nursing confirmed the aforementioned findings.

Based on medical record (MR) review, hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure:

1. All entries in the MR were signed and dated.

2. All entries in the MR were made at the time the care was provided.

3. All MR's were completed within 30 days of patient discharge.

4. The facility was able to calculate the number of incomplete MR's greater than 30 days.

This had the potential to affect all patients served by the facility and did affect MR # 1, and Unsampled Patients #'s 11, 12, 13, 14, 15, 16, and 17 and had the potential to affect all patients served by this facility.

Findings include:

Policy: Documentation Entries in the Medical Record
Date revised: 8/2014

"Purpose: To establish guidelines for clinical documentation entries in the medical record...

Policy:
A. Health care documentation shall conform to the following requirements...

6. Documentation shall reflect the chronological sequence of events as they occurred throughout the patient's hospital stay.
7. Documentation shall be accurate, thorough and, when handwritten, legible.

8. All documentation entries in the medical record....shall be dated, timed, and authenticated with name and credentials/title.

11. All documentation entries...shall be...in ink or be done electronically.

15. All documentation...be completed within 30 days of patient discharge.

a. Medical records not completed within 30 days of discharge shall be considered delinquent.
b. The delinquency rate is measured no less than every three months.
c. The medical record delinquency rate averaged from the last four quarterly measurements shall be 50% or less of the average monthly discharge rate for the last 12 months.

16. All medical record documentation shall be completed timely.
a. Medical record documentation shall be completed within 30 days post discharge."

Policy: Analysis and Completion of Discharged Medical Records
Date revised: 8/4/2014

"Purpose: To establish guidelines for identifying deficient documentation in closed medical records...

Policy:
A. Hill Crest Behavioral Health Services shall maintain a complete and accurate medical record for every individual assessed, treated, or served.

...4. HIM (Health Information Management) staff shall use colored clips to mark deficiencies throughout the medical record for the purpose of identification by clinicians needing to complete a section(s) of the record.
5. HIM staff shall ensure total completion of all closed medical records.
a. All closed medical records should be completed within 30 days of a patient's discharge.
b. Any closed medical record that is not complete within 30 days of discharge shall be deemed delinquent.

Procedure:
...2. Nursing Documentation
A. All Nursing forms shall be reviewed for documentation completeness as well as the date, time and authentication of the recording nurse.
1. Any form lacking documentation, signature, date and/or time will be checked on the Deficiency Slip and the appropriate colored clip will be placed next to the area where the deficiency exits."


1. MR # 1 was admitted to the facility on 1/15/18 with diagnoses including Post Traumatic Stress Disorder without Psychosis and Major Depressive Disorder.

Review of the MR revealed four (4) Significant Events forms, dated 1/18/18 at 8:58 AM, 2/11/18 at 12:43 PM, 2/11/18 at 12:50 PM, and 2/11/18 at 12:52 PM. There was no documentation on 4 of 4 of the Significant Event forms identifying the author, credentials, or signature, per facility policy. During review of the MR on 2/14/18 at 2:00 PM, the surveyor asked Employee Identifier (EI) # 19, Registered Nurse who authored the forms. EI # 19 stated, "The therapists write those."

In an interview on 2/15/18 at 10:50 AM, EI # 5, Nurse Manager, Adolescent Girls, confirmed the above findings.



34107

2. A tour of the Medical Record department was conducted on 2/15/18 at 8:55 AM with EI # 18, Medical Records Director, revealed several shelving units containing stacks and stacks of yellow folders and asked EI # 18 what they were. EI # 18, stated, "All these medical records have incomplete documentation. We are waiting for the clinical staff to make additions/ corrections so they can be filed." The surveyor asked EI # 18, what discipline of clinical staff was she referring to. EI # 18 responded, all staff.

The surveyor noted the following incomplete documentation

1. Unsampled patient # 11 was admitted on 11/1/16 with the diagnosis of Major Depressive Disorder and discharged on 11/30/16.

Review of the MR revealed incomplete documentation by the Infection Control Preventionist.

In an interview conducted on 2/15/18 at 10:00 AM, EI # 18 confirmed the above findings. The incomplete record was greater than 1 year old.

2. Unsampled patient # 12 was admitted on 5/2/17 with the diagnosis of Major Depressive Disorder and discharged on 5/18/17.

Review of the MR revealed the following incomplete documentation identified by medical record staff for:
5/2/17 admission nurse.
5/3/17 Infection Control Preventionist.
5/10/17 Medical Health Technician (MHT).

In an interview conducted on 2/15/18 at 10:00 AM, EI # 18 confirmed the above incomplete record was greater than 6 months old.

3. Unsampled patient # 13 was admitted on 5/30/17 with the diagnosis of Paranoid Schizophrenia and discharged on 8/17/17.

Review of the MR revealed incomplete documentation dated 8/6/17 by the Infection Control Preventionist.

In an interview conducted on 2/15/18 at 10:00 AM, EI # 18 confirmed the above incomplete MR was greater than 30 days.

4. Unsampled patient # 14 was admitted on 6/22/17 with the diagnosis of Schizoaffective Disorder and discharged on 9/7/17.

Review of the MR revealed incomplete documentation for the following disciplines and dates:
Physician - 7/28/17, 8/11/17, 8/18/17, 9/1/17 and 9/7/17.
Social Worker (SW) - 7/28/17 and 8/4/17.
Nursing -7/25/27, 7/29/17, 8/11/17, 8/18/17, and 9/7/17.

In an interview conducted on 2/15/18 at 10:00 AM, EI # 18 confirmed the incomplete MR was greater than 30 days.

5. Unsampled patient # 15 was admitted to the facility on 11/9/17 with the diagnosis of Major Depressive Disorder and discharged on 11/15/17.

Review of the MR revealed incomplete documentation for the nursing staff for the dates of 11/9/17, 11/14/17, and 11/15/17.

In an interview conducted on 2/15/18 at 10:00 AM, EI # 18 confirmed the incomplete MR was greater than 30 days.

6. Unsampled patient # 16 was admitted on 11/28/17 with the diagnosis of Major Depressive Disorder and discharged on 12/5/17.

Review of the MR revealed incomplete documentation for the nurse progress note dated 11/28/17.

In an interview conducted on 2/15/18 at 10:00 AM, EI # 18 confirmed the incomplete MR was greater than 30 days.

7. Unsampled patient # 17 was admitted on 12/4/17 with the diagnosis of Bipolar Disorder and discharged on 12/13/17.

Review of the MR revealed incomplete documention for SW staff dated 12/8/17.

In an interview conducted on 2/15/18 at 10:00 AM, EI # 18 confirmed the incomplete MR was greater than 30 days.

The surveyor asked EI # 18 what was the percentage of medical records that had not been completed within 30 days of discharge as per policy. The response from EI # 18 was the facility was unable to calculate the percentage of incomplete records.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on review of personnel files and interview with staff, it was determined the facility failed to maintain a system for evaluating staff immunization status as recommended by the CDC (Centers for Disease Control) and Prevention and its Advisory Committee on Immunization Practices and provide Hepatitis B Vaccine to personnel when requested. This affected 2 of 8 personnel records reviewed and had the potential to affect all personnel.

Findings include:

Review of 2 of 8 personnel files revealed a signed Consent Statement to receive the Hepatitis B Vaccine (one dated 4/19/16 and one dated 11/22/16). There was no documentation the vaccine had been administered and there was no documentation of follow up by the facility.

An interview conducted on 2/15/18 at 10:15 with Employee Identifier # 16, Human Resources Director, confirmed the above findings.

Based on review of medical records (MR), facility policy and procedure and interviews it was determined the facility failed to ensure:

1) The nurse completed all weekly treatment updates and documented accurate facts concerning prn (as needed) administration and abnormal lab results for weekly team review.

2) All disciplines reviewed and participated in the weekly Interdisciplinary Master Treatment Plan and Updates and all treatment team updates contained signatures of all team members and the physician.

This affected MR's # 6, # 4, and # 1, 3 of 10 records reviewed and had the potential to affect all patients served.

Findings include:

Policy: Interdisciplinary Treatment Plan
Revision Date: 09/13

I. Policy

"...Each patient admitted to the hospital shall have a written treatment plan that is appropriate to the patient's specific assessed needs. The treatment plan will be revised and maintained based on the patient's response to identified interventions...individualized to meet...unique needs...identified through assessment data...Qualified individuals shall ...evaluate and maintain the plan of care using the interdisciplinary approach...

An interdisciplinary team shall plan, review and evaluate the treatment plan at least weekly on the Acute units...The team shall consist of the physician and representatives from each clinical discipline involved in the treatment...ultimate responsibility...for development and implementation, and overall treatment planning process shall rest with the physician....

II. Procedure

3. At least every 7 days as indicated by the acuity and treatment issues the Treatment Plan shall be reviewed and updated on the Acute Units...

Treatment Plan review and updates shall include the following steps as appropriate:
a. Review of progress toward goals and effectiveness of interventions for each active problem on the Master Problem List.
b. Modifications or additions made to problems/goals and interventions as appropriate.
c. Updated discharge plan...justification for continued stay.

5. The Interdisciplinary Treatment Plan Update Form...completed at least every 7 days...description of the patient's progress...barriers to discharge...All parties participating in the treatment plan update...each staff member, including title and discipline, must sign the form...

1. MR # 6 was admitted to the facility on 10/3/17 with a diagnosis of Recurrent Major Depressive Disorder.

Medical record review revealed an Initial Treatment Plan which identified Assaultive/Aggressive (behavior) as Problem 2 and interventions were initiated by nursing staff.

Medical record review revealed the last Interdisciplinary Master Treatment Plan Update and Revisions were documented on 1/25/18. The 1/25/18 Update did not include documentation of a weekly Nurse Update for prn (as needed) medications, medication compliance, abnormal lab results and medical concerns.

There was no signature/date of a Licensed Therapist on the 1/25/18 weekly Treatment team update.

There was no weekly Treatment team meeting documentation and no documentation MR # 6's Interdisciplinary Master Treatment Treatment Plan was reviewed/updated by all team members and the physician the week of 2/1/18. MR # 6 was discharged on 2/5/18.

During an interview on 2/15/18 at 10:58 AM, Employee Identifier (EI) # 2, Nurse Manager, Adolescent Boys Unit confirmed the findings above.

2. MR # 4 was admitted to the facility on 1/5/18 with diagnoses including Unspecified Psychosis not due to a substance.

Review of the Individual Treatment Plan revealed documentation Defiant/Aggressive behaviors were identified as Problem 1.

The medical record contained a 1/30/18 physician order for Depakote (for treatment of aggression in children with Attention Deficit Hyperactivity Disorder) and on 2/1/18 the physician ordered a Depakote level to (Depakote drug level monitoring) and a Liver Function Test for 2/5/18.

Record review revealed Benadryl 25 mg (milligram) by mouth prn for agitation was administered on 2/3/18, on 2/4/18, on 2/5/18 and on 2/6/18.

Review of the Interdisciplinary Master Treatment Plan Update and Revisions completed on 2/8/18 by the nurse failed to include documentation of 4 Benadryl prn's administered from 2/3/18 to 2/6/18. There was no documentation on 2/8/18 the team reviewed the 2/5/18 lab results (which included an abnormal Depakote level of 41, Low (50-100 normal level).

Further review of the Interdisciplinary Master Treatment Plan Update and Revisions completed on 2/8/18 failed to include a physician signature and date the physician approved the plan.

In an interview on 2/15/18 at 10:38 AM, EI # 7, Licensed Counselor, Adolescent Boys Unit confirmed the findings above. EI # 7 reported the physician "attends when he can, he is suppose to be present, we talk to him all the time in the hallway."

On 2/15/18 at 10:40 AM, EI # 2, Nurse Manager Adolescent Boys Unit, confirmed the aforementioned findings.



39098

3. MR # 1 was admitted to the facility on 1/15/18 with diagnoses including Post Traumatic Stress Disorder without Psychosis and Major Depressive Disorder.

MR review revealed no weekly Treatment Team Meeting and no documentation the Interdisciplinary Master Treatment Plan was reviewed/updated by all team members and the physician for the week of 1/28/18.

During an interview on 2/15/18 at 10:50 AM, with EI # 5, Nurse Manager, Adolescent Girls, the above findings were confirmed.

Based on medical record (MR) review, and interview, the facility failed to ensure all patients were provided individualized therapeutic treatments for 1 of 3 patients diagnosed with Paranoid Schizophrenia. This affected MR # 2, and had the potential to negatively affect all patients served by facility.

Findings include:

1. MR # 2 was admitted to the facility on 2/7/18 with diagnoses including Paranoid Schizophrenia.

Review of the 2/9/18 Individual Treatment Plan revealed problem # 1 as Psychosis- making threats to mother. The goal was for the patient to engage in treatment plans, and attend 4 groups per day to develop coping skills, to improve socialization, become educated on the need for medication and compliance.

Review of the 2/8/18, 2/9/18, 2/10/18, 2/11/18, and 2/13/18 group therapy notes revealed documentation of minimal or no input from patient due to paranoid behaviors.

Review of the MR revealed no documentation a group therapy session was offered /or provided to the patient on 2/12/18.

Further review of MR revealed no documentation the staff attempted or completed any 1:1 (one on one) individualized therapy sessions for the patient unable to participate in group therapy due to active paranoid behaviors.

In an interview on 2/15/18 at 10:55 AM, Employee Identifier # 17, Assistant Director of Clinical Services, Licensed Professional Counselor, confirmed the above findings.

Based on medical record (MR) review, Medical Staff Bylaws and staff interviews it was determined the hospital failed to ensure physician progress notes were completed daily, transcribed and inserted in patients' medical records in a timely manner. This failure prevented unit staff from accessing the physician's thinking and assessment of the patient in a timely manner.

This affected MR # 4 and # 6, 2 of 2 adolescent boys records reviewed and had the potential to affect all patients treated at the hospital.

Findings include:

Medical Staff Bylaws
5 December 2017

2.11 All patient admissions:

2.11.5 The attending physician will document at least one daily progress note for Acute patients...

In an interview on 2/14/18 at 10:55 AM, Employee Identifier # 12, Corporate Divisional Clinical Director reported daily Psychiatric Progress notes were to be dictated within 24 hours of service and signed within 48 hours of service.


1. MR # 4 was admitted to the psychiatric hospital on 1/5/18 with diagnoses including Unspecified Psychosis not due to a substance.

Record review on 2/13/18 revealed no daily Psychiatrist Progress Note documentation on 1/15/18 and 1/16/18.

Review of the medical record revealed (3) three daily Psychiatric Progress Notes, date of service was 1/17/18 which included different patient observations, dates/times of dictation and transcription. The three (3) Psychiatric Progress Notes dated 1/17/18 had been electronically signed by the psychiatrist on 1/31/18, 2/5/18 and 2/7/18, which was at least 14 days (or greater) after the service date.

Medical record review on 2/14/18 revealed no Psychiatric Progress Note documentation for 2/6/18 and 2/9/18.

2. MR # 6 was admitted to the psychiatric hospital on 10/3/17 with diagnoses including Recurrent Major Depressive Disorder.

Medical record review on 2/14/18 revealed no Psychiatrist Progress Note documentation for 1/1/18.

Medical record review included Seclusion/Restraint Record documentation dated 1/8/18 at 3:30 PM which revealed a 2 man hold restraint was implemented due to physical aggression to a peer and at 3:32 PM, Ativan 0.5 mg (milligram), Haldol 2 mg and Benadryl 25 mg by mouth were administered.

The Psychiatrist Progress Note, date of service 1/9/18 (Tuesday) was dictated/transcribed on 1/13/18 and signed by the psychiatrist on 1/14/18, 5 days after the service date and contained the following documentation "...In the last 24 hours, he/she did not require any pain [prn] (as needed medication for inappropriate behavior) medications. The daily progress note documentation did not reveal MR # 6's need for 3 prn medications on 1/8/18.

Record review on 2/14/18 revealed no Psychiatrist Progress Note documentation on 1/15/18.

The Psychiatrist Progress Note for service date 1/16/18 revealed the note was dictated/transcribed on 2/5/18 and signed by the psychiatrist on 2/11/18, which was 26 days after the service date.

The Psychiatrist Progress Note for service date 1/18/18 revealed the note was dictated on 1/28/18, transcribed on 1/29/18 and signed by the psychiatrist on 1/31/18, which was 13 days after the service date.

The Psychiatrist Progress Note for service date 1/19/18 (Friday) revealed the note was dictated/transcribed on 1/28/18 and was signed by the psychiatrist on 1/31/18, which was 12 days after the service date.

During an interview on 2/14/18 at 12:50 PM, EI # 6, Psychiatrist, Medical Director confirmed Psychiatric Progress Note documentation had not been completed daily and was not available for staff review.

Based on review of policies and procedure, medical records (MR) and interviews, it was determined the nursing staff failed to:

1) Follow the hospital protocol and physician's order for insulin, vital signs and weights.

2) Notify the physician with changes in the patient's medical and psychiatric health conditions.

3) Ensure patient medical records contained results of all ordered laboratory tests.

4) Perform and document a complete wound assessment for a Stage 3 wound.

5) Document patient behaviors, events PRN (as needed) Administration in the Nurses Progress Notes.

6) Ensure prn medications were administered for ordered patient behaviors, notify the physician for suspected allegeric reaction.

This affected 7 of 10 records reviewed including MR's # 7, # 4, # 9, # 8, # 1, # 2, and # 10, and had the potential to negatively affect all patients served by the facility.

Findings include:

Subject : Insulin Protocol
Number: NSG-F.003
Revised date: 2/17

I. Policy

It is the policy of Hill Crest Behavioral Health Services to provide quality nursing care to all patients. Hill Crest Behavioral Health Services has established an "Insulin Protocol" as a standard procedure to guide nurses in the treatment of diabetic patients who are prescribed insulin. This protocol will be followed until changed or discontinued by the physician or other licensed independent practitioner.

II. Procedure

3. Pattern blood sugars will be obtained before each meal, at bedtime and 2 AM (morning). The results will be documented on the diabetic flow sheet.

****

Subject: Prevention of Wound Infection
Number: NSG-I.045
Revised Date: 12/17

I. Policy
It is the policy of this hospital that all nursing personnel treat wounds in an appropriate manner...

****

Policy: RN (Registered Nurse) 24-hour Chart Checks
Revision Date: 03/06

I. Policy

...the 11-7 (11:00 PM- 7:00 AM) shift nurse to monitor each patient's chart to provide for 24-hour chart monitoring for accuracy and completeness...Each patient's chart will be monitored for medication order transcription accuracy, follow up of physician orders...lab...dressing changes...assessments...

6... When the 11-7 nurse completes the chart audit, any discrepancies will be passed on to the Clinical/Unit Manager....

****

Policy: NSG-J.003, Nursing Documentation in Progress Notes (Acute Services)
Revision Date: 12/12/17

"I. Policy

It is the policy of the Nursing Department to document information relevant to patient care in the progress note section of the medical record on an ongoing basis....

II. Procedure

A. Entries by a nursing staff member will be made at least once every shift on each patient and more often as the patient's condition indicates...

B. ...When the patient's condition warrants... a narrative entry must be made that addresses critical areas... All medical interventions must be documented by the nurse in the Progress Notes..."

*****

1. MR # 7 was admitted to the facility on 1/9/18 with the diagnosis of Bipolar Disorder, Episode Severe Depression, Opioid Dependence, Uncomplicated and Diabetes Mellitus.

Review of the Medication Reconciliation dated 1/9/18 contained the following insulin orders: Insulin Aspart 4 units subcutaneous (SQ) three times a day with meals and Insulin Glargine 300 mg (milligram) SQ at HS (bedtime).

Additional Insulin Orders on sliding scale: Insulin Aspart administer by SQ.
Blood Sugar (BS) 0 - 150 mg/ dL (deciliter) - 0 unit
151 - 200 mg/ dL - 2 units
201- 250 mg/ dL - 4 units
251- 300 mg/dL - 6 units
301- 350 mg/dL - 8 units
351- 400 mg/ dL - 10 units.

Review of the MR dated 1/9/18 revealed the patient's after supper BS was 179 mg/dL. There was no documentation Insulin Aspart 2 units was administered.

Review of the MR dated 1/13/18 revealed the patient's after supper was 186 mg/ dL. There was no documentation Insulin Aspart 2 units was administered.

Review of the MR for 1/26/18, 1/28/18 and 1/29/18 revealed no documentation the patient's blood sugar was checked.

Review of the Group Progress Note dated 1/15/18 at 3:15 PM to 4:00 PM revealed the patient informed the group leader, Employee Identifier (EI) # 13, LMSW (Licensed Master Social Work) that she/ he needed to talk to the doctor about her/ his medication because of feeling too drowsy. There was no documentation the physician was notified of the request.

Review of the Group Progress Note dated 1/18/18 at 3:15 PM to 4:00 PM revealed the patient informed EI # 13 she/ he is still experiencing same side effects from the medications and "thinks she/ he needs to talk to the physician about them". There was no documentation the physician was notified or an arrangement made so patient could speak to the physician.

Review of the Group Progress Note dated 1/23/18 at 3:00 PM to 3:45 PM, the patient informed EI # 14, Licensed Counselor (LC) she/ he knows the medication is helping psychologically "like there are suppose to but I have tremors". There was no documentation the physician was notified of possible medication side effects and/or informed the information to the patient's nurse.

In an interview conducted on 2/15/18 at 10:55 AM with EI # 4, Nurse Manager, Adult Unit who confirmed the above mentioned findings.



30952

2. MR # 4 was admitted to the facility on 1/5/18 with diagnoses including Unspecified Psychosis not due to a substance.

Medical record review revealed a physician order dated 2/1/18 for Liver Function Test (LFT) and Depakote Level on 2/5/18. There were no Depakote and LFT results in the medical record on 2/13/18.

In an interview on 2/13/18 at 12:45 PM, EI # 2, Nurse Manager Adolescent Boys Unit presented the surveyor with lab results obtained after the surveyor identified missing lab results. The lab documentation revealed the specimen was collected 2/5/18 and resulted 2/6/18. EI # 2 reported "the lab had the wrong fax number."

Review of the 2/5/18 lab results revealed an abnormal Depakote level of 41, Low (50-100 normal level).

Record review revealed 24 hour chart checks were completed by nursing staff on 2/6/18 and 2/7/18.

The 24-hour chart monitoring failed to identify the medical record was not complete and was missing lab test results which were ordered 8 days prior.

In an interview on 2/15/18 at 10:38 AM, EI # 2, Nurse Manager Adolescent Boys Unit confirmed the aforementioned findings.



36271

3. MR # 9 was admitted to the facility on 12/5/17 with diagnosis of Paranoid Schizophrenia.

Review of the nursing progress note dated 1/28/18 at 1:41 AM revealed a "stage 3 ulcer noted at coccyx" and a med (medical) consult ordered. There was no documentation of a wound assessment or description of the wound bed, size and/or if there was any drainage. Further, there was no documentation of interventions and/or care provided to the wound.

An interview conducted on 2/15/18 at 10:40 AM with EI # 4, Nurse Manager, Adult, confirmed the above findings.



39098

4. MR # 8 was admitted to the facility on 8/16/17 with the diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the MR revealed a physician's order dated 12/11/17 at 10:35 AM for CBC (Complete Blood Count) with diff (differential) in AM (morning).

Further review of the MR revealed a physician's order dated 12/14/17 at 2:35 PM for "CBC results to chart please." A Nurses Note dated 12/14/17 at 4:40 PM stated, "Lab...called to fax results."

A review of lab results in the MR revealed CBC results with the following information: Date collected- 12/12/17, Date reported 12/13/17.

Further review of the MR revealed a Medical Consult on 1/11/18 at 4:50 PM for "Elevated temperature and general fatigue." Report of the consult performed by the CRNP (Certified Registered Nurse Practitioner), revealed MR # 8's temperature was 101.8, and patient complaints of "I can't walk." The CRNP documents, "R/O (Rule Out) Fever of unknown origin."

Review of the Urinalysis report revealed the following: Date collected 1/12/18, date reported 1/13/18. and results revealed dark yellow, cloudy, urine, with 3+ (plus) bacteria. The report was signed, not dated by the attending physician.

A lab report in the MR contained the following information: Date collected 1/12/18, date received 1/17/18, date reported 1/18/18, with results of CBC with diff, Comprehensive Metabolic Panel, and Creatine Kinase and revealed abnormal lab results, including a White Blood Cell count of 14.4 (reference range listed: 3.4.- 10.8). Two hand written entries on the report by EI # 4, documented results were called to the attending physician and the CRNP, on 1/18/18 at 11:15 AM.

A Nurses Progress Note, dated 1/16/18 at 6:30 AM, documented "...patient refusing labs... finally complied, gait unsteady."

Further review of the MR revealed the patient was transferred on 1/18/18 to a medical inpatient facility for medical stabilization.

Medical record review revealed the 24 hour chart monitoring by the nursing staff failed to ensure lab results were placed in the chart.

During an interview on 2/15/17 at 11:50 AM, with EI # 4, Nurse Manager, Adult, the above findings were confirmed. The surveyor asked EI # 4 if MR # 8 received any treatment for a Urinary Tract Infection, she/he replied, "No."

An interview was conducted via telephone on 2/15/18 at 8:15 AM, with EI # 10, Director of Nursing, to gather information regarding the lab process. EI # 10 stated the nurses also have the ability to pull (lab)results from an online service and confirmed it is the responsibility of the 11 to 7 shift nurse to ensure all lab results are placed in chart.

5. MR # 1 was admitted to the facility on 1/15/18 with diagnoses including Post Traumatic Stress Disorder and Major Depressive Disorder.

MR review revealed a PRN Administration form that contained documentation Benadryl 25 mg (milligrams), po (by mouth) was administered on 2/6/18 at 10:50 AM. "Agitation" was written in the space provided for location of pain.

A review of the Nurses Progress Note dated 2/6/18 revealed there was no documentation of the patient behavior at 10:50 AM.

Further review of the PRN Administration form revealed Benadryl 50 mg, IM (Intramuscular) was administered on 2/6/18 at 11:50 AM. "Possible allergic reaction" was written in the space provided for location of pain.

Further review of the Nurses Progress Note dated 2/6/18 revealed no documentation of a possible allergic reaction, the suspected source of the reaction and the symptoms MR # 1 experienced. There was no documentation the physician was notified of a possible allergic reaction.

In an interview on 2/15/18 at 10:50 AM, EI # 5, Nurse Manager, Adolescent Girls, confirmed the above findings.



34107

6. MR # 2 was admitted to the facility on 2/7/18 with diagnoses including Paranoid Schizophrenia.

Review of the 2/7/18 Admission Orders and Initial Treatment Plan included orders for Psychosocial Assessment Evaluations, Vital Signs to be performed on admission and then daily, and weigh weekly on Saturday.

Review of the 2/7/18 Admission Medication Orders revealed the following:

Ativan 2 mg PO every 6 hours PRN for Mild Agitation.
Ativan 2 mg IM every 6 hours PRN for Severe Agitation.

Benadryl 50 mg PO every 6 hours PRN for Mild Agitation.
Benadryl 50 mg IM every 6 hours PRN for Severe Agitation.

Haldol 5 mg PO every 6 hours PRN for Mild Agitation.
Haldol 5 mg IM every 6 hours PRN for Severe Agitation.

Review of the PRN Administration record dated for 2/7/18 at 11:45 PM revealed documentation that Ativan 2 mg PO, Benadryl 50 mg PO and Haldol 5 mg PO was administered for "Anxious/Manic" (behaviors).


Review of the PRN Administration record dated for 2/8/18 at 11:30 PM revealed documentation that Ativan 2 mg PO, Benadryl 50 mg PO and Haldol 5 mg PO was administered for "Disoriented/ Delusional Bizarre Behavior".

Review of the PRN Administration record dated for 2/10/18 at 10:00 PM revealed documentation that Ativan 2 mg PO, Benadryl 50 mg PO and Haldol 5 mg PO was administered for complaints of delusions and auditory and visual hallucinations.

Review of the PRN Administration record dated for 2/11/18 at 6:00 PM revealed documentation that Ativan 2 mg PO, Benadryl 50 mg PO and Haldol 5 mg PO was administered for "Bizarre, responding to internal stimuli making strange gestures".

Review of the PRN Administration record dated for 2/13/18 at 2:30 AM revealed documentation that Ativan 2 mg PO and Benadryl 50 mg PO was administered for "Anxiety and Hyperverbal".

Review of the PRN Administration record dated for 2/13/18 at 9:30 AM revealed documentation that Ativan 2 mg PO, Benadryl 50 mg PO and Haldol 5 mg PO was administered for "Anxiety and Racing thoughts"..

The staff documented the reason PRN medications were administered and the above reasons were not mild or severe agitation as ordered on 2/8/18.

Review of the Vital Sign Record revealed documentation the patient refused vital signs 2/7/18 at 11:40 AM, on 2/10/18 at 1:15 AM and on 2/12/18 at 4:34 AM. There was no attempt to re-check the patient's vital signs daily as ordered.

Further review of the 2/10/18 Vital Sign Record revealed the patient refused to be weighed at 1:15 AM. There was no documentation the staff attempted to weigh the patient later that day.

In an interview on 2/15/18 at 10:55 AM, EI # 4, Nurse Manager Adult Unit, confirmed the above findings.

7. MR # 10 was admitted to the facility on 1/18/18 with diagnosis including Schizoaffective Disorder.

Review of the 1/18/18 Admission Orders revealed Vital Signs were be performed on admission and then daily, and weigh on admission and then weekly on Saturdays.

Review of the Vital Sign Record form revealed the following weight documentation:
1/18/18- 167 pounds (lbs).
1/22/18- 177.6 lbs
2/3/18- 189.4 lbs

There as no documentation the patient had a bowel movement from 1/20/18 to 1/28/18.

The surveyor submitted the question to EI # 4, was the physician notified the patient went 8 days without a BM and had a 22.4 lb weight gain since admission? The response was "there was no documentation."

Further review of the Vital Sign Record form revealed the following:

1/19/18 4:35 AM refused vital signs.
1/21/18 no documentation the staff attempted to take the patient's vital signs.
1/23/18 6:00 AM refused vital signs.
1/24/18 2:18 AM refused vital signs.
1/25/18 3:01 AM Non compliant.
1/26/18 12:45 AM Non compliant.
1/27/18 2:10 AM refused vital signs.
2/2/18 no documentation the staff attempted to take the patient's vital signs.
2/5/18 no documentation the staff attempted to take the patient's vital signs.
2/8/18 3:42 AM refused vital signs and
2/14/18 2:43 AM Non compliant.

Review of the Nursing Services Rounding report revealed documentation the patient was asleep when the staff had attempted to take vital signs.

There was no documentation the staff attempted to check the patient's vital signs later during the day during waking hours.

In an interview conducted on 2/15/18 at 11:40 AM with EI # 4, confirmed the staff failed to notify the physician of the changes in patient condition and follow orders for care.

Based on review of facility policy, medical records (MR), and interview with the Assistant Clinical Director it was determined the clinical staff failed to complete a psychosocial evaluation for 1 of 10 records per policy. This affected MR # 2 and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Interdisciplinary Treatment Plan
Revision Date: 09/13

I. Policy

"...Each patient admitted to the hospital shall have a written treatment plan that is appropriate to the patient's specific assessed needs. The treatment plan will be revised and maintained based on the patient's response to identified interventions...individualized to meet...unique needs...identified through assessment data...Qualified individuals shall ...evaluate and maintain the plan of care using the interdisciplinary approach...

An interdisciplinary team shall plan, review and evaluate the treatment plan at least weekly on the Acute units...The team shall consist of the physician and representatives from each clinical discipline involved in the treatment...ultimate responsibility...for development and implementation, and overall treatment planning process shall rest with the physician....

II. Procedure

2. Within 72 hours...on Acute Units....the interdisciplinary treatment team shall further develop the patient's treatment plan based on a comprehensive assessment of the presenting problems...emotional, social, and behavioral status. The team will consist of...the Social Worker/Therapist...

1. MR # 2 was admitted to the facility on 2/7/18 with diagnoses including Paranoid Schizophrenia.

Review of the 2/7/18 Admission Orders and Initial Treatment Plan included orders for Psychosocial Assessment to be completed.

Review of the MR revealed the patient refused to complete a Psychosocial Assessment on admission on 2/7/18 and again on 2/9/18.

Review of the MR conducted on 2/13/18 revealed the Psychosocial Assessment had not been completed since admission.

In an interview on 2/15/18 at 10:55 AM, Employee Identifier # 17, Assistant Director of Clinical Services, confirmed the above findings.