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Based on observation, interview, and record review, the hospital failed to ensure the rights to safety for the patients in the BHU were maintained as evidenced by:

1. The risk of contraband that could cause self-harm was not assessed to minimize the hazards through screening for one of 30 sampled patients (Patient 47).

2. The availability of fluids for the patients in the BHU and monitoring of the fluid intake were not ensured for one of 30 sampled patients (Patient 45) who was at risk for dehydration.

3. Monitoring of the risk for falls was not performed with Q 15 minute checks.

These created the increased risk of poor health outcomes to the patients in the hospital.

Findings:

1. The hospital's P&P titled Suicide Risk NSPG 15.01.01 dated 3/3/14, read in part, "Safety checklist is completed when a patient is being admitted to area(s), to ensure the areas is being made as safe as possible for a patient who is at risk for self-harm."

The hospital's P&P titled Suicide Prevention reviewed 6/13, read in part, "Observe unit policy regarding contraband items and searching patient belongings on admission," and "Maintain a safe environment for patients and staff."

1. The medical record of Patient 47 was reviewed on 12/10/14, and showed the patient was admitted on 12/9/14 at 1830 hours. The medical record contained a Psych Nursing Shift Assessment dated 12/9/14 at 2119 hours, which indicated the patient, "had thoughts to jump in front of cars, hang herself, OD on medications."

The Suicide Risk Screen section of the Prime Admission History contained questions regarding the patient's current and past history of suicidal intent and plan, a risk assessment tool, and a Safety Precaution tool to ensure the hazards were removed from the patient and her environment. However, all of the suicide risk and evaluation screen sections on the Prime Admission History were left blank, including the sections for documenting the contraband and medications were removed from the patient, and sections to indicate the dietary tray contents should be checked to ensure the patient did not retain utensils. Cross reference to A0395.

During the interviews with the Nursing Director of Psychiatric Services on 12/10/14 at 1125 hours, and the DON on 12/10/14 at 1345 hours, they both concurred the assessment was blank.

On 12/10/14 at 1200 hours, Patient 47 was interviewed in her room. The patient stated she had picked her room because she liked the private shower. She stated she was allowed to have her room door closed if she wished.

The condition of Patient 47's room, 219, was observed and showed there was a vertical divider in the closet with a hole to accept a closet pole, but there was no pole in it. The 1 1/2-inch hole constituted a hazard because a loop of fabric could be introduced through the hole to create a hanging hazard. The shower was observed and contained a showed handle that did not appear to be a breakaway type. It included a narrow section adjacent to the wall that could be used with a loop of material to constitute a hanging hazard.

During an interview with MD A on 12/10/14 at 1300 hours, she stated the nurse was to do an assessment of each patient. She thought the suicide assessment was part of the regular nursing assessment. She stated Patient 47 had a history of many suicide attempts, including one in the facility seven years prior, in which the patient hid a knife to cut herself.

There was documented evidence to show the safety for a suicidal patient was ensured by removing potential suicide hazards in the form of contraband and room feature hazards.

2. The hospital's P&P titled Plan for Assessment/Reassessment of Patients reviewed 12/13, read in part, "All patients entering (hospital name) will receive an initial assessment, which takes into account their immediate and emerging needs."

The medical record of Patient 45 was reviewed on 12/10/14, and showed the patient was a 72 year old female with a history of dementia, mental illness, and recurrent UTI. She was admitted on 11/12/14, but was transferred from the BHU to a medical floor nine days later due to dehydration. On the medical floor, the patient was given intravenous fluids and antibiotics and returned to the BHU on 11/24/14.

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 0920 hours, he stated the risk of dehydration was not added to the care planning for Patient 45 when she moved back to the BHU because he thought the problem was resolved. He stated water was available 24/7 at the nurses' station upon request and the patients were checked Q 15 minutes. He further stated he was not sure how Patient 45 became dehydrated during her 11/12/14 through 11/21/14 BHU admission.

During an interview with Patient 45 on 12/9/14 at 0905 hours, the patient was seated in a wheelchair in the hallway. She stated she did not feel well but was not able to further describe her discomfort. However, a Patient Note by the RD for Patient 45 dated 11/25/14, indicated the patient was unable to respond when spoken to.

During observations of the patient rooms in the BHU on 12/9 and 12/10/14, no pitchers of fluid were seen in the rooms.

The care plans for Patient 45's admissions on 11/12 and 11/24/14, were reviewed and did not show the patient's functional ability to request or obtain fluid was assessed, the risk of dehydration was identified as a problem, a care plan was developed to prevent recurrent dehydration, her fluid intake was monitored, or fluid was made readily available to the patient. Cross references to A0395, example #1 and A0396, example #4).

3. The hospital's P&P titled Patient Monitoring, Precaution Protocol/Risk Levels reviewed 6/13, read in part, "Documentation of the patient monitoring is on the Patient Observation Record, according to the legend provided on the form."

The medical record of Patient 47 was reviewed on 12/10/14, and showed the patient was identified as being at increased risk for falls. Review of the Risk for Falls Treatment Plan form showed the patient had an unsteady gait secondary to the use of medications. Patient 47 was admitted to the BHU on 12/9/14 at 1830 hours.

The Patient Observation Record for 12/9/14 from 0700 to 1459 hours was reviewed and contained columns to indicate fall risks and whether a bed alarm was in use for each patient in the BHU. Eight patients were identified as having falls risks and bed alarms, including Patient 47.

The Patient Observation Record for 12/9/14 at 1500 hours to 12/10/14 at 0659 hours was reviewed, but the columns for falls risks and bed alarms were blank. Falls risk and bed alarms were not checked for any of the eight patients indicated as having fall risks on the Patient Observation Record in use on 12/9/14 from 1500 to 0659 hours. Patient 47, admitted in the evening, did not have the columns for falls risk and bed alarm checked on the Patient Observation Record dated 12/9/14.

During an interview with the BHU Secretary on 12/10/14 at 1100 hours, he stated the CNAs, unit secretary, or RN did the Q 15 minute patient checks and record their findings on the Patient Observation Record. He further stated the fall risk was not checked off on the 12/9/14 evening and night shifts and should be checked off.

Based on interview and record review, the hospital's QA program failed to ensure the care plans were promptly completed for one of 30 sampled patients (Patient 47) in the BHU and the forms for suicide lethality risks were valid and used correctly, creating the increased risk of adverse health outcomes for the patients in the BHU.

Findings:

1. During an interview with the Director of Quality on 12/9/14 at 1300 hours, he stated the BHU patient treatment plans were individually audited. He stated he sampled treatment plans to validate the audit. He showed the quality data for the audits, which indicated that 100% of the treatment plan updates, including complete and accurate assessments of changes in patient condition, orientation, internal stimuli, progress towards goals, compliance with medications, sleep patterns, oral intake, and activities of daily living.

The medical record of Patient 47 was reviewed on 12/10/14 at 0900 hours, and showed the patient was admitted on 12/9/14 at 1830 hours. The Interdisciplinary Master Treatment Plan showed the reason for admission was danger to self and severe incapacitating anxiety or depression. The medical record contained an Initial Treatment Plan which included the problem, "potential for self-harm," the goal, "will remain free from self-harm per shift, and one intervention," contracts for safety verbally." The medical record also contained a Psych Nursing Shift Assessment completed on 12/9/14 at 2119 hours, which indicated the patient, "had thoughts to jump in front of cars, hang herself, OD on medications."

At the top of the Behavioral Health DTS Treatment Plan, the long term goal, "Patient will be free from suicidal thoughts by discharge" was checked off. The pre-printed form contained a list of short term goals/objectives, such as "will contract for safety daily," "will identify triggers that cause self-harm behaviors daily," and "will verbalize positive way(s) to cope with depression and/or stress daily," but none of the objectives were checked off. That section of the form was left blank. The form was signed at the bottom by five staff members and the psychiatrist. The back of the pre-printed form contained interventions that could be checked off, including seven "Standard Daily Routine Interventions" and two possible methods to employ 1:1 (one to one) monitoring, and space for writing in additional interventions. The "Standard Daily Routine Interventions" included "Monitor every _____ minutes for safety." "Provide safe and supportive environment each shift," etc. The page was also blank except for the signatures of three staff members at the bottom. There were no interventions for the prevention of suicide identified on the Behavioral Health DTS Treatment Plan for Patient 47. Additional treatment plan documents found in the patient's medical record included the Altered Thought Process Treatment Plan, the Alteration in Mood Treatment Plan, and the Risk for Falls Treatment Plan. Each of the pre-printed treatment plans had a long term goal selected via a check mark in a box, but no short term goals or interventions were identified, and each treatment plan had been signed at the bottom by multiple staff members.

During a second interview with the Director of Quality on 12/10/14 at 1350 hours, he stated he had been sampling the care plans for completeness but had not seen the incomplete care plans on the newly arrived BHU patients.

2. The medical record of Patient 47 was reviewed on 12/10/14 at 0900 hours, and showed that the patient was admitted on 12/9/14 at 1830 hours. The medical record contained a Psych Nursing Shift Assessment dated 12/9/14 at 2119 hours, which indicated the patient, "had thoughts to jump in front of cars, hang herself, OD on medications."

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 1110 hours, he stated the suicide lethality assessments were to be done on patients voicing suicidal ideation. He stated the suicide lethality forms should appear in the nursing documentation. He further stated a high score on the risk assessments would result in a different intervention in the care plan.

The Psy Suicide Risk/Lethality assessment tool in the electronic medical record was reviewed on 12/10/14 at 1045 hours, and showed the screening tool contained sections regarding details of the suicidal plan, lethality of the plan, protective factors, loss and level of coping, and substance use. At the bottom, the Psy Suicide Risk/Lethality tool resulted in a "low" "medium" or "high" risk score.

The Psy Suicide Risk/Lethality assessment tool in the electronic medical record of Patient 47 was reviewed and showed some items were left blank and more than one possible choice was selected for one item. The first portion of the tool for the assessment of the suicide plan had not been completed because there were various choices to check off to indicate how specific the plan was, ranging from "vague" to "immediately," but none of the choices had been checked off. The next section was for lethality, which contained three columns of choices. Column one listed plans with 6-23% lethality, including "medication overdose." Column two listed plans with 49-73% lethality, including "hit by automobile." Column three listed plans with 77-99% lethality, including "hanging self." Although Patient 47 had plans in each of the three columns, none of the choices for plan had been checked off. The next portion of the Psy Suicide Risk/Lethality tool listed possible protective factors. A "1" had been inserted next to the factor, "Friends/Family present most of the time, help available, sig others, and a "0" was inserted next to two other factors ("concerned and willing to help " and "direct expression of feelings and suicide intent"). There were six other factors listed, but there were no numbers inserted next to them. The next section was for, "loss and level of coping." One of the choices had a "0" inserted next to it, and three choices had no numbers inserted next to them. Two choices, both "Daily activities continue as usual with little change "and "Moderate reaction to loss or environmental change, some interruption in daily activities, disturbance in eating, school, or work " had a "1" next to them. The last screen of the Psy Suicide Risk/Lethality tool had an item for substance abuse in which two choices were scored as "0" and the third was scored as "1". At the bottom of the pages was a "Summary of Assessed Risk", including a "total score" and three risk levels, low, medium, and high. There was a "Y" in the box opposite "Low risk (1-6)."

During an interview with the DON on 12/10/14 at 1125 hours, she stated a new suicide assessment screen was being implemented, but the policy was still being developed. She stated they were not using the computerized form yet. She further stated there was an additional suicide screening form in use in the BHU.

During the interviews with the Nursing Director of Psychiatric Services on 12/10/14 at 1140 and 1345 hours, he stated the previous suicide assessment screens were replaced with the new ones on the computer eight days prior, but there was no hospital policy on the new suicide assessment screens. He stated he did provide some training on the screens on 11/25/14, by showing the staff the screens during a meeting. He concurred it appeared that the information filled in resulted in the total and risk levels be calculated but was not able to state whether the total and risk levels were valid if the form was only partially completed. He further stated they started using the tool about two weeks prior and there was no follow-up on the efficacy of the tool yet.

During a follow-up interview with the DON, she stated staff had not been trained to use the new suicide screening tool yet, and she needed a policy to train the staff to use the tool.

During an interview with the Director of Quality on 12/10/14 at 1350 hours, he stated he was not aware the new suicide risk assessment tool was implemented. He stated the initial QA of the tool had been performed by the corporate office, but there was no specific plan for QA follow-up of the implementation of the plan in the hospital.

Based on interview and record review, the hospital failed to ensure two of the two transfers from the BHU reviewed (Patients 45 and 63) were analyzed to determine the causes of the adverse events, creating the increased risk of unrecognized poor healthcare practices.

Findings:

1. The hospital's P&P titled Plan for Assessment/Reassessment of Patients reviewed 12/13, read in part, "All patients entering (hospital name) will receive an initial assessment, which takes into account their immediate and emerging needs."

Review of Patient 45's medical record on 12/9/14, showed the patient had a history of dementia, mental illness, and recurrent urinary tract infection.

The patient was admitted to the BHU on 11/12/14; however, the patient was transferred from the BHU to a medical floor nine days later due to dehydration. On the medical floor, the patient was given intravenous fluids and antibiotics, and returned to the BHU on 11/24/14.

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 0920 hours, he stated he was not sure how the patient became dehydrated during her 11/12 through 11/21/14, BHU admission.

Review of the care plans developed for Patient 45's admissions to the BHU on 11/12/14 and readmission on 11/24/14, did not show the patient's functional ability to request or obtain fluids was assessed, the risk of dehydration was identified as a problem, a care plan was developed to prevent recurrent dehydration, or that the patient's fluid intake was monitored. Cross references to A0392, example #3 and A0396, example #4.

During an interview with the DON on 12/10/14 at 1345 hours, she stated there was no documentation to show an analysis of the incident or the reason for transfer was documented.

During an interview with the Performance Improvement Manager on 12/10/14 at 1350 hours, he stated he was not aware Patient 45 was transferred from the BHU due to dehydration. The Manager stated he relied upon the Department Director, DON, or CNO to call for an intensive analysis of a case and the case was not brought to his attention.

2. Patient 63's medical record was reviewed on 12/10/14. The patient was admitted to the BHU on 11/18/14, with a history of psychiatric problems but no history of seizures.

The nursing notes dated 11/18/14 at 2109 hours, indicated the patient was threatening and agitated and the psychiatrist ordered haloperidol (brand name is Haldol, an antipsychotic medication) 10 mg orally.

At 2145 hours, the patient was severely agitated and the psychiatrist ordered Geodon (generic name is ziprasidone, an antipsychotic medication) 20 mg IM At 2220 hours. The nursing note showed "Witnessed seizure after being given Geodon 20 MG IM."

At 2226 hours, an EKG was performed on Patient 63 and showed a sinus (normal) rhythm, and a QTc of 487 (the QTc is a measure of the electrical conduction of the heart [normal less than 440], if prolonged can lead to dangerous irregular heart rhythms).

The FDA drug warnings for ziprasidone included ziprasidone use should be avoided in combination with other drugs that are known to prolong the QTc interval. Additionally, clinicians should be alert to the identification of other drugs that have been consistently observed to prolong the QTc interval. Such drugs should not be prescribed with ziprasidone.

The FDA also issued a warning indicating Haldol could prolong the QTc. The updated labeling includes warning stating that Torsades de Pointes (ventricular tacchycardia) and QT prolongation have been observed in patients receiving haloperidol, especially when the drug is administered intravenously or in higher doses than recommended. Haloperidol is not approved for intravenous use.

Patient 63 was moved back to the ED for evaluation and was then admitted to a medical floor with cardiac monitoring ability. The ED physician's note read, "Given the cardiac nature of these medications patient requires admission to ensure no arrhythmia ensues."

Patient 63 subsequently left the hospital against medical advice.

During an interview with the Director of Pharmacy on 12/10/14 at 1415 hours, he stated he checked the medication-related events log. The Director of Pharmacy stated he was not aware of Patient 63's episode. The Director of Pharmacy stated immediate use single doses of medications were not subject to pharmacy oversight.

Based on observation, interview, and record review, the hospital failed to have an effective and organized nursing service to provide quality care to patients as evidenced by:

1. Nursing staff failed to provide nursing care to meet the needs of four of the 14 patients in the BHU (Patients 45, 47, 54, and 66) and one additional patient (Patient 56) of the 30 total sampled patients. Cross reference to A0392.

2. Nursing staff failed to provide nursing supervision and evaluation for five of the 14 patients in the BHU (Patients 45, 47, 54, 66, and 67) and one additional patient (Patient 3) of the 30 total sampled patients. Cross reference to A0395.

3. Nursing staff failed to develop individualized nursing care plans for five of the 14 patients in the BHU (Patients 45, 47, 54, 66, and 67) and one additional patient (Patient 40) of the 30 total sampled patients. Cross reference to A0396.

4. Nursing staff failed to administer medications following pharmaceutical standards for Patient 40). Cross reference to A0405.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare in a safe environment to the patients in the hospital.

Based on observation, interview, and record review, the hospital failed to ensure nursing care was provided to meet the needs of four of the 14 patients in the BHU (Patients 45, 47, 54, and 66) and one additional patient (Patient 56) of the 30 total sampled patients as evidenced by:

1. Nursing failed to develop a P&P and train staff in the use of an initial nursing suicidal risk assessment in use in the BHU. This resulted in incomplete assessments for two patients (Patients 47 and 66) admitted to the BHU at risk for suicide.

2. Nursing failed to ensure Patient 54 was assessed for risk of dehydration, fluids were offered to the patient, and the patient's fluid intake was monitored.

3. Nursing failed to assess Patient 45's functional deficits to request or obtain fluids was a cause of the dehydration which required the transfer of the patient to the medical floor for treatment nine days after admission to the BHU. In addition, following the patient's transfer back to the BHU, there was no documentation to show the patient was provided assistance with eating and ordered oral dietary supplements were consistently provided to prevent the risk of a reoccurrence of dehydration.

4. Nursing failed to monitor Patient 56's vital signs Q 15 minutes as required by the hospital's P&P during administration of propofol (a sedative) on 11/10/14 from 0345 to 0700 hours.

These failures could lead to inappropriate care to the patients in the hospital.


Findings:

1. Review of the hospital's P&P titled Suicide Prevention reviewed 6/13, showed the purpose of the policy is to safeguard patients who are high risk by history and/or recent behaviors from self-inflicted harm. The policy's procedure showed to assess the patients' condition on admission, including the presence or absence of suicide ideation or intention and documentation on the Admission Suicide Risk Rating Scale. The level of risk is communicated to the physician. The staff was to observe unit policy regarding contraband items and searching patient belongings on admission.

The hospital's P&P titled Suicide Risk NSPG 15.01.01 dated 3/3/14, read in part, "Suicide Risk screen is completed on every patient who is admitted to the Behavioral Health Unit." and "Patients who screen positive for potential risk of self-harm are further assessed using a measurable, evidence based lethality scale to determine the presenting degree of risk on admission, and a second suicide lethality assessment will be done on discharge as well."

Review of the nursing Prime Admission History form was a printed version of the electronic record. The form included 23 screens to record information at the time of admission.

Review of the Psy Suicide Risk/Lethality assessment tool in the electronic medical record showed the screening tool contained sections for risk assessment, details of the suicidal plan, lethality of the plan, protective factors, loss and level of coping, and substance use. At the bottom of the Psy Suicide Risk/Lethality tool showed a "low," "medium," or "high" risk score.

a. The medical record for Patient 47 was reviewed on 12/10/14. The patient was admitted to the BHU the previous night, 12/9/14 at 1830 hours. The record contained a Psych Nursing Shift Assessment dated 12/9/14 at 2119 hours, documenting the patient "had thoughts to jump in front of cars, hang herself, OD on medications."

The psychiatrist's assessment dated 12/9/14, indicated the patient had a history of more than 10 suicide attempts, mostly by overdose or cutting herself. The note also indicated Patient 47 had multiple plans to kill herself.

Seventeen of the 23 screens of Patient 47's Prime Admission History, a time of completion of 12/9/14 at 2251 hours was recorded and a nurse's name was entered; however, all 17 screens on the form were otherwise blank. There were no entries on the form to describe the patient's admission data, vital signs, past medical history, surgeries, admission height/weight allergies, social history, and suicide risk screen, etc.

The Suicide Risk Screen section of Patient 47's Prime Admission History contained questions regarding the patient's current and past history of suicidal intent and plan, a risk assessment tool, and a Safety Precaution tool to ensure that hazards were removed from the patient and her environment. All of the suicide risk and evaluation screen sections on the Prime Admission History were left blank, including the sections to document the contraband and medications were removed from the patient and the sections to indicate the dietary tray contents should be checked to ensure the patient did not retain utensils.

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 1110 hours, he stated a suicide lethality assessment was to be done on patients voicing suicidal ideation. The Director stated the form should appear in the nursing documentation. The Director further stated a high score on the risk assessment would result in a different intervention in the care plan.

During an interview with MD A on 12/10/14 at 1300, she stated Patient 47 had a history of many suicide attempts, including one in the facility seven years prior, in which the patient hid a knife to cut herself. MD A stated she contracted with the patient for safety upon her 12/9/14 admission.

The Psy Suicide Risk/Lethality assessment tool in the electronic medical record of Patient 47 was reviewed on 12/10/14 at 1045 hours. Some items were left blank and more than one possible choice was selected for one item.

The first section of the tool for Patient 47, "Suicide Risk Assessment, consisted of five questions with "Y" (yes) or "N" (no) selected next to each one. Three of the questions read, "Patient has a history of psychiatric conditions, with history of self-harming behavior." and "Patient has a positive history of suicide attempt" and "Patient has an active suicide plan." For each of those questions, an "N" response was selected.

The next portion of the tool, assessment of the suicide plan, was not completed. There were various choices to check off to indicate how specific the plan was, ranging from "vague" to "immediately;" however, none of the choices were checked off.

The next section was for lethality contained three columns of choices. Column one listed plans with 6-23% lethality, including "medication overdose." Column two listed plans with 49-73% lethality, including "hit by automobile." Column three listed plans with 77-99% lethality, including "hanging self." Although Patient 47 had stated plans in each of the three columns, none of these were checked off.

The next portion of the suicide lethality screen listed possible protective factors. A "1" was inserted next to the factor: "Friends/Family present most of the time, help available, significant others. A "0" was inserted next to two other factors ("concerned and willing to help" and "direct expression of feelings and suicide intent").

There were six other factors listed for Patient 47, but no numbers were inserted next to them. The next section was "loss and level of coping." One of the choices had a "0" inserted next to it and three other choices had no number inserted next to them. Two choices, both "Daily activities continue as usual with little change" and "Moderate reaction to loss or environmental change, some interruption in daily activities, disturbance in eating, school, or work" had a "1" next to them.

The last screen of the Psy Suicide Risk/Lethality tool had an item for substance abuse in which two choices were scored as "0" and the third was scored as "1." At the bottom of the pages was a "Summary of Assessed Risk", including a "total score" and three risk levels, low, medium and high. There was a "Y" in the box opposite "Low risk (1-6)."

During an interview with RN G on 12/10/14 at 1110 hours, she stated the question regarding the patient having an active plan related to past behavior. RN G stated the patient heard voices telling her to do things, but she did not have a plan.

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 1125 hours, he confirmed Patient 47's initial nursing assessment was blank, but he was not sure why. The Director stated he thought the assessment might have been done but erased.

During an interview with the DON on 12/10/14 at 1345, she concurred Patient 47's assessment was blank.

b. Review of Patient 66's medical record was initiated on 12/9/14. Patient 66 was admitted to the BHU on 12/6/14, with diagnoses including schizoaffective disorder (mental disorder characterized by abnormal thought processes and deregulated emotions).

Review of a Psychiatric Evaluation dated 12/6/14, showed Patient 66's chief complaint was "I'm very depressed." The psychiatrist documented Patient 66 felt hopeless, helpless, and started having suicidal ideation; the patient called the BHU inpatient unit and asked to be admitted. The psychiatrist documented Patient 66 had history of multiple previous suicide attempts.

Review of the History of Present Illness dated 12/6/14, showed the physician's plan for Patient 66 listed to encourage her to group therapy for her problem of depression.

Review of the Prime Admission History entered and electronically signed by the RN dated 12/6/14, showed six pages of the initial assessment were left blank, including Patient 66's safety evaluation including suicide risk assessment, level of self-care and dependent care, and risk or harm to self and others.

Review of the Patient Care Inquire notes showed RN documentation Patient 66 stated she came to the hospital because she felt depressed and anxious, "she could not stop crying, she just felt like there was no hope." The RN documented Patient 66 denied suicidal or homicidal ideation or hallucinations.

During an interview with MD A on 12/10/14 at 1300 hours, she stated the nurse was to do an assessment of each patient. MD A stated she thought the suicide assessment was part of the regular nursing assessment. MD A stated she performed her physician assessment separately and the nurse was to tell her if the patient was felt to be in danger.

During an interview with the DON on 12/10/14 at 1125 hours, she stated a new suicide assessment screen was being implemented, but the policy was still being developed. The DON stated nursing was not using the computerized form yet. The DON stated there was an additional suicide screening form in use in the BHU.

During the interviews with the Nursing Director of Psychiatric Services on 12/10/14 at 1140 and 1345 hours, he stated the previous suicide assessment screens were replaced with the new ones on the computer eight days prior; however, there was no hospital policy on the new suicide lethality assessment screens yet.

The Director stated he did provide some training on the screens on 11/25/14, by showing the staff the screens during a meeting. The Director displayed "will populate to the appropriate risk box after the total score has been calculated." The Director concurred it appeared that the information filled in resulted calculation of a risk total and risk level; however, he was not able to state whether the total and risk levels at the bottom were valid if the form was only partially completed.

During a follow-up interview with the DON, she stated staff were not trained to use the new suicide lethality screening tool yet; she needed a policy to train the staff to use the tool.

2. Review of Patient 54's medical record was initiated on 12/9/14. Patient 54 was admitted to the hospital's BHU on 12/2/14, with a diagnosis of major depressive disorder with psychotic features (depression along with loss of touch with reality).

Review of the History and Physical dated 12/2/14, showed Patient 54 had history of urinary incontinence.

Review of the Psychiatric Evaluation dated 12/2/14, showed Patient 54 was admitted to BHU because she had a severely depressed mood, and was anxious, tearful, and crying nonstop. The psychiatrist's evaluation of the symptoms of mental illness showed Patient 54 had poor insight and poor judgment.

Review of a laboratory report dated 12/8/14, (six days after admission) showed Patient 54's BUN level was increased at 24 mg/dl (normal range: 7-18 mg/dl), possibly indicating dehydration.

Review of the urinalysis result dated 12/5/14, showed Patient 54's urine was yellow and hazy, and contained moderate bacteria. The leukocytes count was 100 (normal is negative) and the red blood cell count was 25 (normal is negative). According to the CDC, all of these were positive signs and symptoms of a UTI.

Review of the physician's order dated 12/5/14, showed an order for Ampicillin (antibiotic) 500 mg every six hours.

Observation of the BHU kitchen showed the Ice Machine/Water dispenser and nourishment station were located inside the nurses' station under staff control.

Review of the Nutrition Low/Moderate Risk Assessment documented by the RD dated 12/2/14, showed Patient 54 was at low nutritional risk and staff were to monitor the patient's oral intake, weight, and laboratory results. The RD documented Patient 54 was on regular food and had no fluid restrictions.

During an interview with RN O on 12/10/14 at 1100 hours, he stated Patient 54 knew how to get fluids very well; if she wanted a water pitcher with water in her room, we could provide one.

An interview with Patient 54 was conducted on 12/9/14 at 1000 hours. Patient 54 was observed alone in her room. The patient stated she did not know where the water dispenser was located. The patient stated she was not offered morning snacks.

During an interview with the Charge Nurse on 12/9/14 at 1005 hours, he stated the staff did not routinely record the patients' fluid intake; only if there was a physician's order for strict intake and output monitoring.

Review of the Percentage Meal Taken: Record forms from 12/3 to 12/8/14, showed the sections to document the percentages of the snack intakes (nutritional supplements) for 1000 and 1400 hours and sleep snacks were left blank.

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 0900 hours, the Director was asked how the patient's goals for fluid intake were monitored on a daily basis. The Director stated the patients' diet and fluids intake were monitored and documented as "tolerated."

The Director stated patients' labs results were also reviewed and should be within normal range. The Director confirmed staff were not completing the "snacks intake form" by recording intake percentage to ensure the patients' intakes were meeting their needs.

During a follow-up interview on 12/10/14 at 0930 hours, the Director of Psychiatric Services verified there were no additional hospital policies that addressed assessment/monitoring of fluid intake.

3. The hospital's P&P titled Plan for Assessment/Reassessment of Patients dated 12/12, read in part, "All patients entering (hospital name) will receive an initial assessment, which takes into account their immediate and emerging needs. The data gathered will be analyzed to create information needed for care decisions concerning any need for further assessments, treatment, interventions, and reassessments." and "Assessment will be performed by a Registered Nurse (RN) and include the following as relevant to the care, treatment, and services provided: ...Functional Screen...Nutritional Screen...Functional/Environmental Needs..."

The medical record of Patient 45 was reviewed on 12/9/14. The patient had a history of dementia, and mental illness, and recurrent UTI. The patient was admitted to the BHU on 11/12/14, but was transferred from the BHU to a medical floor on 11/21/14, due to dehydration as evidenced by an increase in the BUN and Creatinine (two measures of chemicals in the blood that can indicate dehydration), lethargy, and a UTI.

Patient 45's BUN increased from 24 (normal range: 7-18 mg/dl) on 11/17/14, to 67 on 11/21/14. Her creatinine increased from 1.1 (normal range: 0.7-1.3 mg/dl) on 11/17/14, to 1.7 on 11/21/14. On the medical floor, the patient was given intravenous fluids and antibiotics and was returned to the BHU on 11/24/14.

The treatment plans for Patient 45's initial admission and readmission to the BHU on 11/12 and 11/24/14, were reviewed. There was no documentation to show the risk of dehydration was assessed and identified as a problem for the patient on either dates.

Patient 45's History and Physical Addendum provided by MD B upon readmission to the BHU on 11/24/14, included schizoaffective disorder, recurrent UTI, history of dehydration, anemia, history of seizure disorder, diabetes, neuropathy, hypertension, gastroesophageal reflux disease, history of breast cancer, history of scabies, history of stroke, dementia, and history of chronic kidney disease.

The RD's Nutrition Assessments for Patient 45, dated 11/21/14, showed the patient was at "moderate/high nutritional risk," and that her oral intake fluctuated but improved with feeding assistance. The assessment indicated the patient was to receive a mechanical soft diet with finely chopped meats, no sugar added, and mighty shakes three times per day.

A Patient Note by the RD dated 11/25/14, indicated Patient 45 was unable to respond when spoken to and that her average diet intake with the additional consumption of mighty shakes met her dietary needs.

Review of the Nourishment List Report for 12/9/14, showed the diet prepared by the kitchen for Patient 45 was to include a mechanical chopped soft diet and mighty shakes three times per day, along with a sandwich at bedtime.

Review of the Psychiatric Nursing Shift Assessment for Patient 45 dated 12/9/14 at 0017 hours, showed Patient 45 was withdrawn, isolative, gravely disabled, and lacking insight. The Assessment also showed the patient needed total care with feeding, the nurse documented there was no choking, and the patient tolerated diet and fluids. However, there was no documentation to show feeding assistance was provided.

Review of the Nutrition Monitor sheets for Patient 45 showed on 12/3/14, the percentage of intake of for breakfast, lunch, and dinner were recorded, but no supplements or bedtime snacks were documented. On 12/4/14, the percentage of breakfast and lunch consumed were recorded, but no amount of dinner, supplements, or bedtime snack were documented.

On 12/5/14, the percentage of breakfast, lunch, and dinner eaten was recorded and the percentage of supplement taken at dinnertime, but there was no record of a supplement consumed at breakfast or lunch, or a bedtime snack.

On 12/6/14 and 12/7/14, the percentage of the three meals was recorded, but not the percentage of supplements or bedtime snack was documented.

On 12/8/14, the percentage consumed of three meals and a bedtime snack were recorded, but not the supplements consumed. The consumption of the supplemental mighty shake was documented on only one of 18 meals reviewed. The consumption of a bedtime snack was recorded on only one of six occasions reviewed. There was no separate record of fluids consumed.

During an interview with the Director of Food Service on 12/10/14 at 0905 hours, she stated there was a nursing note in Patient 45's medical record to encourage fluids; however, it was not documented if this had occurred.

When asked if assistance with feeding was documented in the nursing notes, the Director of Food Service was able to find documentation of assistance provided only on 11/23/14 at breakfast time and 11/24/14 at dinner time. The Director stated there was a way to remind the nurse that feeding assistance was needed via a note in the electronic diet record system, but such notes were not currently made.

During the interviews with the Nursing Director of Psychiatric Services on 12/9/14 at 1050 hours and 12/10/14 at 0915 and 0925 hours, he stated Patient 45 ate in her room on 12/9 and 12/10/14. He was not sure if feeding assistance was documented. The Director stated there was no separate record of fluid intake for Patient 45. He was not sure why a snack was not filled in on her intake documentation.

4. Review of the hospital's P&P titled Propofol (medication used for sedation during procedures and for sedation in intubated, mechanically-ventilated ICU patients) Infusion Guidelines for Ventilator Patients revised 8/14, showed vital signs monitoring Q 15 minutes is needed to monitor hemodynamic response and keep SBP equal or above 90 mmHg.

Review of Patient 56's medical record was initiated on 12/10/14. The patient was admitted to the hospital on 11/9/14.

Review of the physician's order dated 11/9/14 at 0416 hours, showed intravenous propofol to run at 20.2 ml per hour, start propofol at 10 mcg per kg per minute, titrate up to 100 mcg per kg per minute, and titrate to a sedation RASS score of minus two.

Review of the IV (intravenous) Drip Monitoring form showed Patient 56 received continuous propofol 50 mcg per kg per minute (or 16.8 ml per hour) on 11/10/14 at 0300, 0400, and 0500 hours, increasing to 60 mcg per kg per minute (or 20.2 ml per hour) on 11/10/14 at 0600 and 0700 hours. Propofol was stopped at 0800 hours.

Review of the Vital Signs record showed Patient 56's vital signs were taken on 11/10/14 at 0345 and at 0700 hours. However, there was no documented evidence to show Patient 56's vital signs were monitored Q 15 minutes on 11/10/14 from 0345 to 0700 hours.

An interview and concurrent medical record review was conducted with RN L on 12/10/14 at 1430 hours. When asked, the RN was unable to find documented evidence to show Patient 56's vital signs were monitored Q 15 minutes when the patient received propofol on 11/10/14 from 0345 to 0700 hours.

26756




25720

Based on observation, interview, and record review, the hospital failed to ensure the RN supervision and evaluation of the nursing care for five of the 14 patients in the BHU (Patients 45, 47, 54, 66, and 67) and one additional patient (Patient 3) of the 30 total sampled patients as evidenced by:

1. The Nursing Director of Psychiatric Services failed to provide adequate oversight to ensure standards of nursing care were provided when the Master Treatment Plans for five of the 14 BHU patients (Patients 45, 47, 54, 66, and 67) were found not individualized and not complete.

2. The shift nursing assessment for Patient 3 was not completed by the RN.

These failures created the risk of substandard health outcomes for the patients in the hospital.

Findings:

1. The hospital's job description for the Nursing Director of Psychiatric Services was reviewed on 7/8/14. Documentation showed the Director had 24 hour responsibility to supervise, coordinate, and evaluate nursing care in the BHU in accordance with the RN Practice Act, Standard of Practice, and facility P&Ps. The Director was to supervise/coordinate all nursing activities to achieve and maintain efficient and competent nursing practices. The Director oversees the provision of patient care for adults and older adult patients.

The Director was to direct and supervise complex patient care situations and complex patient care problems and ensure basic care was provided promptly and efficiently in a holistic manner. In addition, the Director was to collaborate with the Program Director in the implementation of the philosophy and objectives for the BHU.

Review of the Master Treatment Plans for Patients 45, 47, 54, 66, and 67 did not show nursing interventions were individualized (focused) for the patients. The treatment plans included nursing interventions which were generic and did not address the patients' individualized needs. Not addressing individualized interventions resulted in lack of guidance to staff in providing individualized nursing care. Cross reference to A0396, examples #1, #2, #3, #4, and #5.

2. Review of the hospital's P&P titled Plan for Assessment/Reassessment of Patients reviewed 12/13, showed a RN shall assess the patient's need for nursing care in all settings where nursing care is provided. The patient will be reassessed by a "Registered Nurse," minimal every shift and at unit specified interval related to care setting and course of treatment. Documentation of the reassessment will be in the patient's chart.

Review of the CMS-2567 Statement of Deficiencies and Plan of Correction for the Complaint Validation survey completed on 7/9/14, showed the hospital's POC with a completion date of 11/5/14. The POC showed to restructure the charting format, so only RNs could document the assessment, reassessment, and shift assessment for the patients.

Patient 3's medical record was initiated on 12/9/14. The patient was admitted to the hospital on 11/1/14.

Review of the Shift Assessment dated 11/24/14 at 0800 hours, showed LVN 1 (not the RN) completed and documented the Shift Assessment for Patient 3.

During an interview and concurrent medical record review with the DON on 12/10/14 at 1345 hours, the DON confirmed the finding.


26881

25720

Based on observation, interview, and record review, the hospital failed to ensure nursing staff developed individualized nursing care plans for five of the 14 patients in the BHU (Patients 45, 47, 54, 66, and 67) and one additional patient (Patient 40) of the 30 total sampled patients, creating the increased risk of substandard health outcomes for the patients.

Findings:

Review of the hospital's P&P titled Mature Adult Inpatient Psychiatric Services reviewed on 7/14, showed each patient will have a written individualized Interdisciplinary Treatment Plan that is based on an assessment of his/her needs.

Upon completion of the admission assessments, the nursing staff will initiate a preliminary plan of care based on pressing psychiatric and medical needs demonstrated by the patient. The preliminary plan of care, which guides treatment while the remaining initial assessments are being completed, consists of initial entries placed on the interdisciplinary Treatment Plan form within eight hours of admission.

Each treatment plan should have a signature with first initial and last name and professional title of the persons who participated in the Interdisciplinary Treatment Planning Meeting "on the attendance section of the treatment plan."

Review of the hospital's CMS-2567 Statement of Deficiencies and Plan of Correction for the Complaint Validation survey completed on 7/9/14, showed the hospital's POC with a completion date of 11/5/14. The POC showed the P&P for care planning was reviewed and BHU RNs were re-educated to address inclusion of the need to use medical and psychiatric care planning as individualized and address psychiatric and medical problems. The Nursing Director of Psychiatric Services was responsible for the the POC.

1. Review of Patient 66's medical record was initiated on 12/9/14. Patient 66 was admitted to the BHU on 12/6/14, with diagnoses including schizoaffective disorder.

Review of a Psychiatric Evaluation dated 12/6/14, showed Patient 66's chief of complaint was "I'm very depressed." The Psychiatrist documented Patient 66 was feeling hopeless, helpless, and started having suicidal ideation. The patient called the inpatient unit and asked to be admitted. The Psychiatrist documented Patient 66 had a history of multiple previous suicide attempts.

Review of the History of Present Illness dated 12/6/14, showed the physician's plan for Patient 66 listed to encourage her to group therapy for her problem of depression, fall risk precautions, give multivitamin for her medical problem of protein malnutrition, administer Lisinopril for her medical problem of hypertension and Percocet for her medical problem of pain due to chronic scoliosis, and avoid fluid overload for her history of heart failure.

Review of the Patient Care Inquire notes showed the RN documented Patient 66 stated she came to the hospital because she felt depressed and anxious, "she could not stop crying, she just felt like there was no hope." The RN documented Patient 66 denied sucicidal or homocidal ideation or hallucinations.

Review of the Patient 66's Interdisciplinary Treatment Plan dated 12/6/14, showed for Problem #1: Alteration in mood due to acute symptom/History of: "Patient verbalized increased anxiety and feels hopeless and helpless." The short term goal was for Patient 66 to identify three positive coping skills per week for two weeks.

The short term interventions developed for the patient were composed of a pre-printed treatment plan written in terms of expected behavior that was generic and not individualized to Patient 66. The only intervention listed was for the staff to educate the patient about positive ways to cope for five days. There was no documentation to show how the ways to cope would be determined. In addition, there was no documentation to show standard daily routine interventions to provide a safe and supportive environment for the patient.

During an interview and concurrent medical record review with the Nursing Director Psychiatric Services on 12/10/14 at 1300 hours, he was unable to explain why no interventions were developed in the care plan to address the patient's suicidal ideation.

2. Review of Patient 54's medical record was initiated on 12/9/14. Patient 54 was admitted to the hospital's BHU on 12/2/14, with diagnosis of major depressive disorder with psychotic features.

Review of a Laboratory Report dated 12/8/14, (six days after admission) showed Patient 66's BUN level was 24 mg/dl.

Review of the urinalysis results dated 12/5/14, showed Patient 54's urine was yellow and hazy, and contained moderate bacteria. The leukocytes count was 100 and the red blood cell count was 25. According to the CDC, all of these are positive signs and symptoms of a UTI.

Review of Patient 54's Infection/Inflammation Treatment Plan to address the acute symptoms of increased leukocytes in the urine and UTI dated 12/2/14, showed the measurable desired outcomes were for the patient to be medication compliant for seven consecutive days.

The interventions were pre-printed and generic interventions to assess the patient for signs and symptoms of infection, increase of pain, elevated temperature, and dysuria (pain on urination) every shift for seven days. However, there was no documentation to show if the patient required assistance from staff with drinking or eating. The care plan did not establish if the patient was able to access fluids on her own or was aware of the need to drink. There was no established fluid goal to prevent dehydration. There were no interventions to monitor output, encourage fluids, and monitor laboratory results.

Review of Patient 54's The Behavioral Health Alteration in Mood Treatment Plan dated 12/2/14, showed a plan to address the problem of isolation, withdrawal, and trouble sleeping. The nursing interventions listed were to ask the patient to verbalize decrease in depression daily. However, there were no interventions developed to guide staff on how to manage Patient 54's problem of isolation and trouble sleeping.

Review of Patient 54's The Behavioral Health Sleep Pattern, Disturbance Treatment Plan dated 12/2/14, showed the measurable desired outcome was for Patient 54 to have eight and half hours of sleep every night. Pre-printed interventions showed to monitor the patient's night time routine for dysfunctional patterns and monitor for day sleeping every shift.

Review of Patient 54's The Behavioral Health Altered Thought Process Treatment Plan dated 12/2/14, to address auditory hallucinations "voices telling her to harm herself." The nursing interventions listed were to ask the patient regarding command auditory hallucinations and suicidal ideation each shift.

Although the risks of suicide and self-harm were well known by staff, the IDT failed to implement interventions for daily routine monitoring of the patient for safety and failed to communicate the risks of suicide and self-harm within the team.

3. Review of Patient 67's medical record was initiated on 12/9/14. Patient 67 was readmitted to the BHU on 12/8/14, with a diagnosis of major depression.

Review of a History and Physical dated 12/3/14, showed Patient 67 was initially admitted to the medical floor for bacteremia from urosepsis (severe infection that starts in the urinary tract and spreads into the bloodstream). The urosepsis was resolved and the antibiotic completed. The patient was transferred to the BHU for management of an underlying schizoaffective disorder. Patient 67 became weaker, was sweating with increased temperature and confusion, and was transferred back to the medical floor.

Review of the Psychiatric Inquiry/Intake dated 12/8/14, showed Patient 67 had the following medical concerns: contact isolation due to MDRO, BUN level of 32 mg/dl, urosepsis , chronic constipation, hyperlipedemia (high cholesterol), hyponatremia (low sodium), failure to thrive with severe protein malnutrition, history of bacteremia, kidney failure, and chronic pain syndrome. Patient 67 was on a mechanical soft (easy to chew) diet and was dependent on staff for all the activities of daily living.

Review of the Behavioral Health dated 12/8/14, showed the Interdisciplinary Master Treatment Plan for Patient 67 was initiated by nursing. The attendance section of the treatment plans were signed by MD A, the activity therapist, and the social worker on 12/8/14. The team identified Patient 67 had problems of anxiety, COPD, urosepsis, poor dentition, generalized level of pain, generalized weakness, an unsteady gait, and discharge. However, there was no documented evidence to show the IDT developed interventions on the treatment plan to address the patient's psychiatric and medical problems as the treatment plan sections to document interventions were left blank. The IDT failed to develop long term goals, short term goals, and interventions for the patient's care plans.

During a concurrent interview and medical record review with the Nursing Director of Psychiatric Services on 12/10/14 at 1100 hours, the Director was made aware of the above findings. The Director of BHU further stated the IDT was still under the time frame to complete the treatment plan interventions up for the first 72 hours of admission.

4. The hospital's P&P titled Plan for Assessment/Reassessment of Patients dated 12/12, read in part, "Care decisions will be based upon data and information gathered in assessments and reassessments. This data will be utilized in prioritizing patient care needs and selecting appropriate interventions."

During an interview with Patient 45 on 12/9/14 at 0905 hours, the elderly woman was seated in a wheelchair in the hallway. The patient stated she did not feel well but was not able to further describe her discomfort.

The medical record of Patient 45 was reviewed on 12/9/14. The patient had a history of dementia, mental illness, and recurrent UTI. She was admitted to the BHU on 11/12/14, but was transferred from the BHU to a medical floor on 11/21/14, due to dehydration as evidenced by an increase in the BUN and Creatinine, lethargy, and a UTI.

Patient 45's BUN increased from 24 on 11/17/14, to 67 on 11/21/14. Her creatinine increased from 1.1 on 11/17/14, to 1.7 on 11/21/14. On the medical floor, the patient was given intravenous fluids and antibiotics and was returned to the BHU on 11/24/14.

Review of the care plan for Patient 45's admissions to the BHU on 11/12 and 11/24/14, did not show a care plan was developed to prevent recurrent dehydration.

The Behavioral Health Alteration in Mood Treatment Plan dated 11/24/14, showed the patient was, "Helpless and hopeless, no interaction with peers, minimal interaction with staff." The patient's Initial Treatment Plan dated 11/24/14, showed the patient had self-care deficits, including unable to feed self, unable to bathe self, unable to dress self, unable to groom self, and unable to ambulate independently. However, there was no specific notation about inability to sense thirst, request, or obtain fluids.

During an interview with the Nursing Director of Psychiatric Services on 12/10/14 at 0920 hours, he stated the risk of dehydration was not added to the care planning for Patient 45 when she was transferred back to the BHU from the medical floor because he thought the problem was resolved. The Director stated water was available 24/7 at the nurses' station upon request and the patients were checked Q 15 minutes. The Director stated he was not sure how the patient became dehydrated during her 11/12 through 11/21/14, BHU admission.

The History and Physical Addendum for Patient 45 provided by MD B upon readmission to the BHU on 11/24/14, included schizoaffective disorder, recurrent UTI, history of dehydration, anemia, history of seizure disorder, diabetes, neuropathy (nerve pain), hypertension (high blood pressure), gastroesophageal reflux disease, history of breast cancer, history of scabies, history of stroke, dementia, and history of chronic kidney disease.

However, most of the problems identified by MD B were not included in the treatment plan developed for Patient 45 even though the physician indicated a desire to encourage the patient's fluid intake and monitor the patient's anemia, seizure activity, neurological status, mental status, and renal function.

5. The hospital's P&P titled Suicide Prevention reviewed 6/13, read in part, "Maintain a safe environment for patients and staff."

The medical record of Patient 47 was reviewed on 12/10/14 at 0900 hours. The patient was admitted to the BHU on 12/9/14 at 1830 hours. The Interdisciplinary Master Treatment Plan showed the reason for admission was danger to self and severe incapacitating anxiety or depression.

An Initial Treatment Plan included the problem "potential for self-harm," the goal was "will remain free from self-harm per shift, and one intervention," and "contracts for safety verbally."

A Psych Nursing Shift Assessment dated 12/9/14 at 2119 hours, indicated the patient "had thoughts to jump in front of cars, hang herself, OD on medications."

At the top of the Behavioral Health DTS Treatment Plan showed the long term goal of "Patient will be free from suicidal thoughts by discharge" was checked off.

The pre-printed form also contained a list of short term goals/objectives, such as "will contract for safety daily," "will identify triggers that cause self-harm behaviors daily," and "will verbalize positive way(s) to cope with depression and/or stress daily;" however, the section of the form was left blank and none of the objectives were checked off.

The form was signed at the bottom by five staff members and the psychiatrist. The back of the pre-printed form contained interventions to check off, including seven "Standard Daily Routine Interventions" and two possible methods to employ 1:1 monitoring, and space for adding additional interventions.

The "Standard Daily Routine Interventions" included "Monitor every (blank) minutes for safety" and "Provide safe and supportive environment each shift" etc. The page was blank except for the signatures of three staff members at the bottom. No interventions for the prevention of suicide were identified on the Behavioral Health DTS Treatment Plan for Patient 47.

Additional treatment plan documents found in the patient's record included: Altered Thought Process Treatment Plan, Alteration in Mood Treatment Plan, and Risk for Falls Treatment Plan. Each of these pre-printed treatment plans had a long term goal selected via a check mark in a box, but no short term goals or interventions were identified. Each treatment plan was signed at the bottom by multiple staff members.

The medical record did contain a contract for safety signed by Patient 47 upon admission.

During the interviews with the Nursing Director of Psychiatric Services on 12/9/14 at 0915 hours and 12/10/14 at 0935 hours, he stated patient goals were identified in the morning flash meeting; care planning occurred through team meetings in which they discussed the issues they thought would affect the patient's safety. However, he stated he liked to wait 48 hours prior to setting goals for the patients.

The Director stated signing the forms indicated the major problems were acknowledged although there was no care plan on the page as this would be filled in later. The Director acknowledged it was not possible to tell if the staff who signed the bottom of the form agreed with the intervention that would be written in later, above their signature. The Director concurred when asked, a suicidal patient might need more urgent treatment.

During an interview with MD A on 12/10/14 at 1300 hours, she stated she thought the nursing staff would fill in the nursing care plan for Patient 47's danger to self within eight hours of admission.

Patient 47 was interviewed in her room on 12/10/14 at 1200 hours. The patient state she chose her room because she liked the private shower. The patient stated she was allowed to have her room door closed if she wished.

Observation of Patient 47's room showed a vertical divider in the closet with a hole to accept a closet pole, but there was no pole. The one 1/2-inch hole potentially constituted a hazard as a loop of fabric could be introduced through the hole to create a hanging hazard. The shower contained a showed handle that did not appear to be a breakaway type. It included a narrow section adjacent to the wall that could be used with a loop of material to constitute a hanging hazard.

During an interview with the AT on 12/10/14 at 1200 hours, she stated she was familiar with Patient 47 and was aware the patient had a history of multiple admissions for suicidal ideation and a history of suicide attempts.

6. Review of Patient 40's medical record was initiated on 12/9/14. The patient was admitted to the hospital on 11/25/14.

Review of a physician's telephone order dated 11/25/14 at 2045 hours, showed to administer Colace (a stool softener) 100 mg and Milk of Magnesia 30 ml every day.

Review of the physician's orders showed an order to administer Lactulose (an ammonium detoxicant or a laxative) 30 mg daily, starting on 11/28/14 at 0900 hours.

According to Lexicomp Online (a drug reference) for the use of Colace, Lactulose, and Milk of Magnesia, diarrhea is one of side effects. One of the geriatric considerations for the use of Milk of Magnesia is for the elderly due to disease or drug therapy, which may be predisposed to diarrhea; diarrhea may result in electrolyte imbalance.

Review of the List Patient Notes showed on 12/8/14 at 0000 and at 0600 hours, Patient 40 had small loose bowel movements.

Review of the Progress Notes showed an entry dated 12/8/14 at 0700 hours, documented by a wound care nurse. Patient 40 had redness noted on peri-rectal area with multiple episodes of diarrhea. The patient was on laxative.

Review of the Shift Assessment dated 12/8/14 at 0800 hours, showed Patient 40 had diarrhea/liquid stool.

Review of the MAR showed Colace and Lactulose were held for Patient 40 on 12/8/14; however, the patient was administered with Milk of Magnesia on 12/8/14 at 1013 hours.

The Shift Assessment dated 12/9/14 at 0830 hours, showed Patient 40 had very loose bowels.

Review of the care plan failed to show a care plan was developed to address care for Patient 40 when the patient had diarrhea/liquid stool and was receiving laxatives and stool softener.

An interview and concurrent medical record review was conducted with RN L on 12/9/14 at 1315 hours. When asked, the RN was unable to find a care plan was developed to address care for Patient 40 when the patient developed diarrhea/loose stool on 12/8/14.








26881

Based on observation, interview, and record review, the hospital failed to ensure nursing staff administered the medications following pharmaceutical standards for one of 30 sampled patients (Patient 40) when a laxative was not held for the patient who had diarrhea or loose stools. This failure had the potential for the risk of dehydration and skin breakdown for the patient.

Findings:

Review of the hospital's P&P titled Medication, Administration Of reviewed 9/13, showed to monitor the patient's response to the medication and discussed expected and potential side effects of medication to include all new medication with the patient. If the patient had an adverse drug reaction/allergy reaction, they will be monitored. The nurse will document information regarding the reaction in the medical record.

Review of Patient 40's medical record was initiated on 12/9/14. The patient was admitted to the hospital on 11/25/14.

Review of a physician's telephone order dated 11/25/14 at 2045 hours, showed to administer Colace (a stool softener) 100 mg and Milk of Magnesia 30 ml every day.

Review of the physician's orders showed to administer Lactulose (an ammonium detoxicant or a laxative) 30 mg daily, starting on 11/28/14 at 0900 hours.

According to Lexicomp Online (a drug reference) for the use of Colace, Lactulose, and Milk of Magnesia, diarrhea is one of side effects. One of the geriatric considerations for the use of Milk of Magnesia is for the elderly due to disease or drug therapy, which may be predisposed to diarrhea; diarrhea may result in electrolyte imbalance.

Review of the List Patient Notes showed on 12/8/14 at 0000 and at 0600 hours, Patient 40 had a small loose bowel movement.

Review of the Progress Notes showed an entry dated 12/8/14 at 0700 hours, by a wound care nurse, Patient 40 had redness noted on peri-rectal area with multiple episodes of diarrhea. The patient was on laxative.

Review of the Shift Assessment dated 12/8/14 at 0800 hours, showed Patient 40 had diarrhea/liquid stools.

Review of the MAR showed Colace and Lactulose were held for Patient 40 on 12/8/14; however, the patient was administered Milk of Magnesia on 12/8/14 at 1013 hours.

Review of List Patient Notes showed a late entry dated 12/10/14, for the event that occurred 12/8/14 at 1930 hours, that Patient 40's family member did not want the patient to have a stool softener. Only give medication as the patient's family member requested. The physician was on the unit and was notified.

The Shift Assessment dated 12/8/14 at 1600 and 2000 hours, and 12/9/14 at 0400 hours, showed the patient had soft and formed stools.

The Shift Assessment dated 12/9/14 at 0830 hours, showed Patient 40 had very loose bowels.

Review of the List Patient Notes showed on 12/9/14 at 0930 hours, Patient 40 had very loose stools. Lactulose, Colace, and Milk of Magnesia were held.

An interview and concurrent medical record review was conducted with RN L on 12/9/14 at 1145 hours. The RN stated the nursing staff held Colace and Lactulose on 12/8/14, due to Patient 40's liquid stool; however, the nursing staff administered Milk of Magnesia to the patient on 12/8/14 at 1013 hours. Colace, Lactulose, and Milk of Magnesia were held today because the patient had diarrhea. When asked, the RN was unable to find a reason why Milk of Magnesia was not also held when the patient had diarrhea.

During an interview with RN M on 12/10/14 at 1315 hours, the RN stated the patient had very loose stools and skin excoriation from the loose stools.

29558




25720

Based on observation, interview, and record review, the hospital failed to ensure complete and accurate medical records for five of 30 sampled patients (Patients 50, 54, 66, 67, and 63). This had the potential for lack of integrity of the medical records.

Findings:

Review of the hospital's P&P titled Medical Staff Rules & Regulations showed entries should be made as soon as possible after clinical events occur to ensure accuracy and to provide information relevant to the patient's continuing care. Medical records must be completed promptly and authenticated or signed by a practitioner within 14 days following the patient's discharge. "Completeness" implies that the content of any dictated record had been transcribed and authenticated.

1. Review of Patient 50's medical record was initiated on 12/10/14. The patient was admitted to the hospital on 11/20/14, and was discharged on 11/21/14.

Review of the Death Summary showed the summary was dictated on 12/10/14 at 0849 hours, 19 days after the occurrence.

During an interview and concurrent medical record review with the DON on 12/10/14 at 1515 hours, the DON confirmed the finding.

2. Review of the hospital's P&P titled General Documentation Guidelines dated 2/14, showed all health records of the Hospital's patients shall be documented in an accurate, complete, and consistent manner to facilitate patient care and foster continuity of care among providers.

Review of the hospital's CMS-2567 Statement of Deficiency and Plan of Correction for the Complaint Validation survey completed on 7/9/14, showed a written POC with a completion date of 11/5/14. The POC showed individualized care plans would include matching the patients' diagnosis, chief of complaints, and specific psychiatric and medical needs. The Director of BHU was responsible to monitor for compliance.

Review of Patient 54's medical record was initiated on 12/9/14. Patient 54 was admitted to the hospital's BHU on 12/2/14.

Review of the Patient 54's Interdisciplinary Master Treatment Plan form dated 12/2/14, showed the forms were left blank; the patient's strengths and limitations and the discharge criteria were not identified.

The section for Psychiatric Diagnosis (DSM-IV) only contained the AXIS I: Major Depression with acute psychosis; AXIS II, III, IV, and V were left blank. There was no diagnosis that served as the primary focus in the treatment plan, compromising the IDT's ability to deliver clinically focused treatment.

3. Review of Patient 66's medical record was initiated on 12/9/14. Patient 66 was admitted to the BHU on 12/6/14, with diagnoses including schizoaffective disorder.

a. Review of the Prime Admission History entered and electronically signed by the RN dated 12/6/14, showed the six pages of the initial assessment were left blank, including suicide risk assessment and evaluation screen.

During an interview with the DON on 12/10/14 at 1100 hours, she stated it could have been a glitch in the computer electronic system which deleted the RN's initial assessment on the computer.

b. Review of the Patient 66's Interdisciplinary Master Treatment Plan form dated 12/6/14, showed the IDT failed to identify the patient's criteria for discharge. The section on the form was left blank.

c. Further review of the Interdisciplinary Master Treatment Plan form dated 12/6/14, showed the section for Psychiatric Diagnosis (DSM-IV) only contained AXIS I: Major Depression with acute psychosis; AXIS II, III, IV, and V diagnoses were left blank.

4. Review of Patient 67's medical record was initiated on 12/9/14. Patient 67 was admitted to the BHU on 12/3/14.

Review of the Interdisciplinary Master Treatment Plan form dated 12/8/14, showed the IDT failed to identify the patient's preliminary discharge plan, strengths, and limitations; these sections on the form were left blank.

Further review of the Interdisciplinary Master Treatment Plan form dated 12/8/14, showed the section for Psychiatric Diagnosis (DSM-IV) only contained AXIS I: Major Depression; AXIS II, III, IV, and V diagnoses were left blank.

During a concurrent interview and medical record review with the Nursing Director of Psychiatric Services on 12/9/14 at 1400 hours, he was made aware of the above findings.

5. The closed medical record for Patient 63 was reviewed on 12/10/14. The discharge summary from his 11/19/14 hospital departure was dictated on 12/5/14, and signed on 12/8/14, 19 days after discharge.


26881

Based on observation, interview, and record review, the hospital failed to ensure an effective system for controlling the spread of infections for three of 30 sampled patients (Patients 3, 40, and 67) as evidenced by:

1. Staff failed to follow contact isolation precautions when caring for Patient 67 in the BHU.

2. The physician failed to document a renewal assessment order and a daily assessment for the continuing need for a urinary catheter for Patient 3.

3. Nursing staff failed to ensure Patient 40's urinary drainage bag was not in contact with the floor.

Failures to follow established infection control practices might allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Findings:

1. According to the CDC's 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, when applying standard precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated.

However, when contact precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by standard precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces.

Review of the hospital's P&P titled Contact Precautions reviewed 2/13, showed in addition to standard precautions, use contact precautions for specific patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin to skin contact that occurs when performing patient care activities that require touching the patients' dry skin) or indirect contact (touching) with environmental surfaces or patient care items in the patients' environment.

On 12/9/14 at approximately 0915 hours, the BHU was toured with the Nursing Director of Psychiatric Services. A photocopied sign posted outside Patient 67's door showed the patient was on contact isolation precautions; hand washing, gowns, and gloves were all marked as necessary precautions for use with this patient. PPE supplies such as gloves and gowns were available inside the nurses' station, outside the patient's room.

On 12/9/14, multiple observations were made in the BHU. The following was identified:

At 0920 hours, Patient 67 was observed outside her room, in her wheelchair in the hallway.

At approximately at 0930 hours, LVN 2 touched Patient 67's forearms with her bare hands to scan the patient's armband prior to administering medications, without wearing gloves or sanitizing her hands.

At approximately at 1115 hours, AT 2 wheeled Patient 67's wheelchair to the Activities Therapy room. The AT was not wearing gloves or a gown.

At approximately 1230 hours, MD A was observed inside the room standing and talking close to Patient 67's bed. MD A was not wearing a gown or gloves.

An interview was conducted with RN G on 12/10/14 at 1215 hours. RN G confirmed Patient 67 was on contact isolation. RN G stated the contact isolation was required as the patient tested positive for ESBL in the urine.

During an interview on 12/9/14 at 1400 hours, with the Infection Control RN, the RN was asked how the staff knew what precautions were needed prior to entering the patients' room. The RN stated there were several ways, first they should look at the sign next to the door to the patient's room; it indicated exactly what type of isolation precautions and PPE they must wear before entering the room. The RN stated PPE was needed due to unexpected contact with the patient and when interactions with the environment were anticipated.

During a follow-up interview on 12/10/14 at 0930 hours, the Infection Control RN stated she verified there were no additional facility policies to show modified isolation precautions were to be used for patients in the BHU.

2. Review of the hospital's P&P titled Urinary Catheter reviewed 7/14, showed physician must document daily a urinary catheter is still necessary. A renewal assessment order will be placed into the electronic health record daily.

Review of Patient 3's medical record was initiated on 12/9/14 with RN L. The patient was admitted to the hospital on 11/1/14. T he patient had a history of urinary retention.

Review of the physician's order for Patient 3 dated 11/24 (no year documented), showed to insert an indwelling urinary catheter (a thin, sterile tube inserted into the bladder to drain urine).

Review of the physician's telephone order dated 11/24 (no year documented) at 1433 hours, showed a daily assessment for the continuing need for an indwelling urinary catheter.

Review of the physician's orders in the electronic health record showed eight template orders for the continuing need for an indwelling urinary catheter were not completed by the physician for Patient 3 as follows: 11/26 at 0600 hours, 11/27 at 0500 hours, 11/28 at 0632 hours, 11/30 at 0600 hours, 12/1 at 0600 hours, 12/6 at 0600 hours, and 12/8 at 0600 hours. The sections to document "continuation is identified by physician," "if urinary catheter still needed, check all that apply," and "management of acute urinary retention and/or obstruction" were all left blank.

During an interview with RN L on 12/9/14 at 12/9/14 at 0905 hours, the RN confirmed the above findings. The RN stated if the physician did not complete a daily order to continue the indwelling urinary catheter, the nurse was to contact the physician for the order.

3. According to the CDC Guideline for Prevention of Catheter-associated Urinary Tract Infection, one of the proper techniques for urinary catheter maintenance is to maintain unobstructed urine flow, including not to rest the bag on the floor and to prevent contact of the drainage spigot with the nonsterile collecting container.

On 12/9/14 at 1125 hours, accompanied by RN L and RN M, Patient 40 was observed lying on the bed. The patient had an indwelling urinary catheter. The urine was amber with red sediment. The drainage valve of the urinary drainage bag was observed resting on the floor. Staff confirmed the observation.