The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAPTIST MEDICAL CENTER SOUTH 2105 EAST SOUTH BOULEVARD MONTGOMERY, AL 36116 Nov. 18, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of policy and procedures, review of medical records and interview it was determined the hospital failed to:

1. Ensure physician restraint orders included:

a. The type of restraint to be used
b. The duration and time limit for the restraint
c. The Manual Hold reason and order to be used.

2. Have signed orders for restraints within 24 hours per hospital policy.


This had the potential to affect all patients served and did affect Patient Identifier (PI) # 4 and # 5.

Findings include:

Refer to A 164, A 166 and A 168.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on review of medical records (MR), review of policy and procedure and interview it was determined the facility failed to:

1. Ensure orders and documentation was present in the medical record for restraints and seclusion.

This affected 2 of 2 patients restrained and did affect Patient Identifier (PI) # 4, # 5 and had the potential to affect all patients at this facility.

Findings include:

Patient Care Policy and Procedure:
Restraint and Seclusion:

" I. Purpose: The purpose of this policy is to provide guidelines for the management and use of restraint or seclusion.

E. Monitoring
1. The frequency of monitoring should be determined based on the assessed needs of the patient...However, patients restrained for violent or self-destructive behaviors will be monitored at least every 15 minutes...

H. Documentation
1. One hour in-person evaluation of restraint and seclusion used to manage violent or self-destructive behavior...
11. The patient's understanding of the criteria that must be met for the removal of restraint/seclusion...
13. Patient assessment/reassessment and monitoring...

VII. Equipment/Form
A. Restraint Flow Sheet
B. Physical Restraint Devices"

Manual Hold Packet:
QA (Quality Assurance)_ Complete and turn in to Charge Nurse/ Nurse manager.

" Manual hold form- complete entire form-leave in the chart for Dr. (doctor) to sign within 24 hours...
One hour face to face must be completed within an hour of the initiation of the manual hold (document on form)
Family to be notified with consent-please document notification or reason there was no notification
FMS (Family Medical Services) consult must be placed...
This event must be added to the IPOC (Interdisciplinary Plan of Care)..."



1. PI # 4 was admitted to the facility 10/6/16 with diagnoses of Schizoaffective Disorder Bipolar Type, Suicidal Ideations and Severe Borderline Personality Disorder.

The Interdisciplinary Progress Notes dated 10/6/16 at 11:20 PM included documentation, " Then she/he started hitting her/his head against the doors, staff attempted to de-escalate patient. Patient is a threat to her/him-self and not re-directable, place patient in 4 point soft restraints..."

The Interdisciplinary Progress Notes dated 10/6/16 at 11:45 PM included documentation, " Released patient from 4 point restraint criteria was met...patient remains in open safe room."

The medical record provided to the surveyor 11/15/16 failed to have the following documentation for the restraint used 10/6/16:

Documentation of the patient's understanding of the criteria that must be met for the removal of restraint/seclusion. Documentation of the patient assessment/reassessment and monitoring tool. The restraint flow sheet was not present in the medical record provided to the surveyor to review for assessment of the patient while in restraint.


A Physician Order Sheet for Restraint/Seclusion was in the medical record dated 10/7/16 verbal order at 6:19 AM, " Behavioral Management, type- bilateral soft wrist and ankle, 4 point, duration 4 hours."

The nurses interdisciplinary progress note failed to include documentation the patient was in restraints 10/7/16.

The Physician Order Sheet for Restraint/Seclusion contains documentation the MD (physician) must sign the order within 24 hours.

A Physician Order Sheet for Restraint/Seclusion was in the medical record dated 10/8/16 at 11:05 AM, " This patient was never placed in restraints." signed by an RN (Registered Nurse) name is not legible. The physician signed the form 10/11/16 at 11:00 AM, 3 days after the order was written.

The Interdisciplinary Progress Notes dated 10/8/16 at 8:20 PM included documentation, " Security was called and Code R (Restraint) called because patient (Pt) attempted to hit staff. Pt was then returned to her/his room with assistance from security...Pt was placed in 4 point restraints because she/he would not re-direct and continued to lash out at staff."

The Interdisciplinary Progress Notes dated 10/8/16 at 9:15 PM included documentation, " Face to face assessment. Pt was released from restraints and...room."

The Physician's Order form dated 10/8/16 at 8:55 PM included an order, " Place pt in restraints due to being combative with staff."

A face to face evaluation form was in the medical record dated 10/8/16 at 11:05 AM, type of intervention/ seclusion, " Pt in seclusion room from 11:05 AM- 12:00 PM."

There was no order for the patient to be placed in seclusion 10/8/16 only an order for restraints.

The medical record provided to the surveyor 11/15/16 failed to have the following documentation:
Documentation of the patient's understanding of the criteria that must be met for the removal of restraint/seclusion. Documentation of the patient assessment/reassessment and monitoring tool. The restraint flow sheet was not present in the medical record provided to the surveyor to review for assessment of the patient while in restraint.

In written questions provided to Employee Identifier (EI) # 3, Nurse Supervisor, 11/16/16 at 4:00 PM the surveyor requested information that was missing from the medical record regarding the use of restraints and seclusion. In an e-mail from EI # 6, Accrediting Coordinator 11/18/16 at 7:45 AM, it was confirmed there was no further nursing documentation to submit.

2. PI # 5 was admitted to the facility 6/28/16 with diagnoses of Schizophrenia Bipolar Type, Psychosis, Altered Mental Status and living on the streets.

On 7/12/16 at 1:31 PM, " With staff assistance and manual hold, medication administered in left gluteal. Pt immediately released..."

On 7/12/16 at 1:42 PM, " Pt continues to rage in hallway yelling, threatening staff...pt at this time required a manual hold to be placed in seclusion ... 2:50 PM pt continues to spit and smear stuff on the window in seclusion room remains on seclusion."

On 7/12/16 at 3:10 PM FMS (Family Medical Services) reconsult-manual hold...physician was not allowed in the room hence was not able to evaluate the patient.

On 7/12/16 at 3:25 PM, " The FMS documented a manual hold- 1st for injection, 2nd for seclusion no injury to patient."

The medical record failed to include a manual hold order form for 7/12/16.

In an interview 11/17/16 at 7:55 AM with EI # 3, Nurse Supervisor the above information was confirmed.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on review of medical records (MR), review of policy and procedure and interview it was determined the facility failed to document accurately a patient's status regarding use of restraint or use of seclusion in 1 of 2 patients reviewed who had orders for restraint/seclusion. This affected Patient Identifier (PI) # 4 and had the potential to affect all patients in this facility.

Findings include:


Patient Care Policy and Procedure:
Restraint and Seclusion:

" I. Purpose: The purpose pf this policy is to provide guidelines for the management and use of restraint or seclusion.

II. Scope
This policy applies to all hospital patients when the use of restraint or seclusion becomes necessary, regardless of patient location, age or diagnosis...

IV. Definitions of Terms:

K. Seclusion- the involuntary confinement of a patient alone in a room or area where he/she is physically prevented from leaving; usually in a locked room; may only be used for the management of violent or self destructive behavior...

V. Policy
It is the policy of Baptist Health that:
A. Restraint or seclusion will only be used to protect the immediate physical safety of the patient, staff or others. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm...

C. Clinical justified restraints may be used at Baptist Health for:
2. Violent or self destructive behavior that threatened the patient, staff or others...

M. Alternatives to restraints or seclusion use will be attempted as applicable. Non-physical interventions are the preferred interventions. Restraint or seclusion will only be used when clinically justified or warranted by patient behavior that threatens the physical safety of the patient, staff or others."



1. PI # 4 was admitted to the facility 10/6/16 with diagnoses of Schizoaffective Disorder Bipolar Type, Suicidal Ideations and Severe Borderline Personality Disorder.

The Physician's Order form dated 10/8/16 at 8:55 PM included an order, " Place pt in restraints due to being combative with staff."

A face to face evaluation form was in the medical record dated 10/8/16 at 11:05 AM, type of intervention/ seclusion, " Pt in seclusion room from 11:05 AM- 12:00 PM."

There was no order for the patient to be placed in seclusion 10/8/16 only an order for restraints.

A Hold Form dated 10/8/16 at 8:27 PM until 8:38 PM, " Reason for manual hold: Danger to self, Danger to Others, Administration of IM (Intramuscular Injection) or Other: Placed in seclusion an restraints."

The one hour face to face evaluation documented at 10/8/16 at 9:15 PM on the hold form failed to document, " Was the patient having behaviors that indicated a need for a manual hold? Yes/No. Had less restrictive interventions been tried and failed prior to manual hold? Yes/No. Based on direct observation of the patient and the situation, was a manual hold appropriate and necessary for this patient? Yes/No. "

The Interdisciplinary Progress Notes dated 10/9/16 at 10:15 (unknown AM or PM) included documentation , " FMS (Facility Medical Services) re-consulted because manual hold of patient... There is bilateral swelling in the area of parotid glands...1. Manual hold, no bruises on the body noted, old cuts on the upper extremities..."


In written questions provided to Employee Identifier (EI) # 3, Nurse Supervisor, 11/16/16 at 4:00 PM the surveyor requested information that was missing from the medical record regarding the use of restraints and seclusion. In an e-mail from EI # 6, Accrediting Coordinator 11/18/16 at 7:45 AM, it was confirmed there was no further nursing documentation to submit.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on the review of medical records (MR), review of policy and procedure and interview it was determined in 2 of 2 records reviewed with restraint orders the physician failed to include:

a. The type of restraint to be used
b. The duration and time limit for the restraint
c. The Manual Hold reason and order to be used.

This affected Patient Identifier (PI) # 4 and # 5 and had the potential to affect all patients restrained in the facility.

Findings include:

Patient Care Policy and Procedure:
Restraint and Seclusion:

" I. Purpose: The purpose of this policy is to provide guidelines for the management and use of restraint or seclusion.

II. Scope
This policy applies to all hospital patients when the use of restraint or seclusion becomes necessary, regardless of patient location, age or diagnosis...

V. Policy
It is the policy of Baptist Health that:
A. Restraint or seclusion will only be used to protect the immediate physical safety of the patient, staff or others. The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm...

C. Clinical justified restraints may be used at Baptist Health for:
2. Violent or self destructive behavior that threatened the patient, staff or others...

G. The use of restraint or seclusion will be addressed in the patient's plan of care and/or treatment plan and updated/revised as indicated.

M. Alternatives to restraints or seclusion use will be attempted as applicable. Non-physical interventions are the preferred interventions. Restraint or seclusion will only be used when clinically justified or warranted by patient behavior that threatens the physical safety of the patient, staff or others.

N. Restraint or seclusion will only be used with an order from a physician or other authorized licensed independent practitioner (LIP) primarily responsible for the patient's ongoing care...

Q. Seclusion will only be used for management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others...

VI. Procedures

B. Physician's Orders
1. Orders for restraint or seclusion must be either written or verbally given by a physician...

4. Orders for restraint/seclusion must contain the following elements:
a. Date and time
b. Reason for restraint/seclusion
c. Type of restraint/seclusion to be used
d. Duration (time limit) for restraint or seclusion
e. If verbal order, signature of RN (Registered Nurse) writing order
f. Physician signature, date and time

5. The time limits for restraint and seclusion orders are as follows:
b. Violent or self-destructive behavior
1) Up to 4 hours for adults 18 years and older...

E. Monitoring
1. The frequency of monitoring should be determined based on the assessed needs of the patient...However, patients restrained for violent or self-destructive behaviors will be monitored at least every 15 minutes...

H. Documentation
1. One hour in-person evaluation of restraint and seclusion used to manage violent or self-destructive behavior...
11. The patient's understanding of the criteria that must be met for the removal of restraint/seclusion...
13. Patient assessment/reassessment and monitoring...

VII. Equipment/Form
A. Restraint Flow Sheet
B. Physical Restraint Devices
C. Alternative to Restraint Devices..."

Manual Hold Packet:
QA (Quality Assurance)_ Complete and turn in to Charge Nurse/ Nurse manager.

" Manual hold form- complete entire form-leave in the chart for Dr. (doctor) to sign within 24 hours...
One hour face to face must be completed within an hour of the initiation of the manual hold (document on form)
Family to be notified with consent-please document notification or reason there was no notification
FMS consult must be placed...
This event must be added to the IPOC (Interdisciplinary Plan of care)..."


1. PI # 4 was admitted to the facility 10/6/16 with diagnoses of Schizoaffective Disorder Bipolar Type, Suicidal Ideations and Severe Borderline Personality Disorder.

The Physician's Order form dated 10/8/16 at 8:55 PM included an order, " Place patient in restraints due to being combative with staff."

The order failed to include the type of restraint to be used and the duration/time of the restraint to be used.

A Hold Form dated 10/8/16 at 8:27 PM until 8:38 PM, " Reason for manual hold: Danger to self, Danger to Others, Administration of IM (Intramuscular Injection) or Other: Placed in seclusion an restraints."

The one hour face to face evaluation documented at 10/8/16 at 9:15 PM on the hold form failed to document, " Was the patient having behaviors that indicated a need for a manual hold? Yes/No. Had less restrictive interventions been tried and failed prior to manual hold? Yes/No. Based on direct observation of the patient and the situation, was a manual hold appropriate and necessary for this patient? Yes/No. "

The Physician's Order form dated 10/8/16 at 8:55 PM included, " FMS consult R/T (related to) Manual Hold per policy." This was a verbal order documented by a Registered Nurse (RN) 10/8/16 at 9:00 PM.

In written questions provided to Employee Identifier (EI) # 3, Nurse Supervisor, 11/16/16 at 4:00 PM the surveyor requested information that was missing from the medical record regarding the use of restraints and seclusion. In an e-mail from EI # 6, Accrediting Coordinator 11/18/16 at 7:45 AM, it was confirmed there was no further nursing documentation to submit.


2. PI # 5 was admitted to the facility 6/28/16 with diagnoses of Schizophrenia Bipolar Type, Psychosis, Altered Mental Status and living on the streets.

On 7/12/16 at 1:31 PM, " With staff assistance and manual hold, medication administered in left gluteal. Pt immediately released..."

On 7/12/16 at 1:42 PM, " Pt continues to rage in hallway yelling, threatening staff...pt at this time required a manual hold to be placed in seclusion ... 2:50 PM pt continues to spit and smear stuff on the window in secluion room remains on seclusion."

On 7/12/16 at 3:10 PM FMS reconsult-manual hold...physician was not allowed in the room hence was not able to evaluate the patient.

On 7/12/16 at 3:25 PM, " The FMS documented a manual hold- 1st for injection, 2nd for seclusion no injury to patient."

The medical record failed to include a manual hold order form for 7/12/16.

On 7/12/16 at 5:15 PM, " Pt awake room door open pt came out calmer stating ready to eat."

The Physician's Order Sheet dated 7/12/16 circled Seclusion as the choice for the order. The verbal order was taken by a Registered Nurse at 1:46 PM and marked Restraint for Behavioral Management duration 4 hours.

The verbal order was co-signed by the physician 7/14/16 at 11:40 AM or 7/19/16 at 11:40 AM the exact date is illegible but is greater than the 24 hours allowed for the physician to co-sign the order.

In an interview 11/17/16 at 7:55 AM with EI # 3, Nurse Supervisor the above information was confirmed.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of medical records (MR), facility policies and interviews with the staff, it was determined the facility failed to ensure:

1. Care plans were updated as needed.

2. A designated Director of Nursing was in place.

3. The nursing staff :

a) Identified, assessed and documented all wounds.

b) Ensured the physician's orders for Computerized Tomography were followed.

Findings include:

Refer to A 386, A 392 and A 396.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation and interview it was determined the facility failed to have a designated Director of Nursing in place at the PPS (Prospective Payment System) Psychiatric unit during the complaint survey.
This had the potential to affect all patients served.

Findings include:

On arrival at the facility 11/15/16 at 8:00 AM, the surveyors met with Employee Identifier (EI) # 2, Administrator at the Psychiatric facility. The surveyors asked to speak with the Director of Nursing and Administrator to discuss the reason for the complaint survey.

EI # 2 responded that they were currently without a Director of Nursing and that between he, the Administrator who is a Registered Nurse and one of the Nursing Supervisors, EI # 3 they were covering the vacant position.

EI # 3 worked with the surveyors during the visit but when asked her role in filling in as the Director of Nursing on 11/15/16 at 2:00 PM she denied any knowledge only that she was doing what EI # 2 had asked her to do during our visit.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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

a) Identify, assess and document all wounds per policy.

b) Ensure the physician's orders for Computerized Tomography were followed.

This affected 1 of 2 patients reviewed with wounds and 1 of 1 patient scheduled for an outpatient procedure and had the potential to affect all patients served by this facility. This affected Patient Identifier (PI) # 4 and # 5.


Findings include:

Patient Care Policy and Procedure Manual
Wound Care: Care of the Patient with Loss of Skin Integrity, Skin Care and Wound Care

" I. Purpose: The purpose of this policy is to provide a plan of care for a patient whose skin assessment reveals abnormalities...

VI. Procedure:
A. The patient's primary nurse will institute the appropriate wound care protocols when a skin abnormality is discovered. The protocol will be chosen based on the appearance of the wound as well as its location and history...
C. The nurse will document the following in the electronic chart:
Type or Classification: Cause of wound if possible...
Location
Size: (If able) length x (by) width x depth in cm (centimeters)...
Wound bed: color, presence of bone, tendon, slough, eschar, sutures, granulation tissue...
Exudate: amount, type, color
Odor: if present
Surrounding skin: Intact, ulcerations, macerations, rash
Wound edges: rolled over or closed
Sign/symptoms of [DIAGNOSES REDACTED]
Pain: Change in pain. Increased pain in a wound can indicate an infection...
Comorbidities: Diabetes, COPD (Chronic Obstructive Pulmonary Disease), Cardiovascular history...

VII. Patients admitted with a Wound
A. The staff nurse may initiate certain types of wound care based on the wound's appearance until the wound can be assessed by the appropriate physician...
1. Cellulitis without blisters or open areas:
Elevation of area with good skin care..."


1. PI # 4 was admitted to the facility 10/6/16 with diagnoses of [DIAGNOSES REDACTED]

A physician's order was present in the medical record dated 10/9/16 for a CT (Computerized Tomography) Maxillafacial (parotid gland bilateral) without contrast.

Interdisciplinary Progress Notes dated 10/10/16 included documentation, " 12:04 PM call received from CT stating patient had an allergic reaction to the contrast dye. Patient (Pt) developed shortness of breath and wheezing..."

The physician's order for a CT without contrast was not followed.

The patient returned from the hospital at 3:00 PM after CT scan, remains on LOS (line of sight).

Interdisciplinary Progress Notes dated 10/10/16 at 8:00 PM included documentation, " Pt came to wrap up group and snack time, pt ate one teaspoon apple sauce and complained of SOB (shortness of breath), pt having difficulty breathing, audible wheezing noted..."

8:25 PM Ambulance here to transfer to acute hospital.

In written questions provided to Employee Identifier (EI) # 3, Nurse Supervisor, 11/16/16 at 4:00 PM the surveyor requested information regarding the use of contrast when it was specifically ordered, " No contrast." In an e-mail from EI # 6, Accrediting Coordinator 11/18/16 at 7:45 AM, it was confirmed there was no further nursing documentation to submit.

2. PI # 5 was admitted to the facility 6/28/16 with diagnoses of [DIAGNOSES REDACTED]

The Psychiatric Evaluation/History and Physical documented History of Present Illness:" This [AGE] year old male/female is admitted emergently. He/she has a long history of schizophrenia. He/she was found in a ditch, grossly psychotic, eaten up by fire ants, very agitated, anxious, irritable... He/she was treated for infection and then transferred over here.(Psychiatric Hospital)."

The nursing assessment dated [DATE] at 4:55 PM included Integumentary: Skin pink, warm and dry. The anatomical figure on the form included bilateral lower legs circled and written insect bites, laceration to forehead area, old wound and numerous old cuts to heels and bottom of feet. The date 7/6/16 was written in the area with the anatomical figure, it is unknown if this was the date of all of the documentation or a part of it.

The nursing summary attached to the assessment included documentation from 6/28/16 at 6:00 PM, " Patient (pt) is blurting out obscene sounds. Refuses to answer questions and be interviewed...Pt stated he wanted to eat but refused to accept the meal offered. Pt." The sentence was not completed by the nurse after she started the sentence with Pt...

The following documentation is from the Interdisciplinary Progress Notes:

PI # 5 was medicated with PRN (as needed) medications 6/29/16 at 3:35 AM with Benadryl 50 mg (milligrams), Ativan 2 mg and Haldol 5 mg IM (intramuscular) and Percocet tablet one for complaint of pain. The patient had complained of back pain earlier.

The patient received Benadryl 50 mg, Ativan 2 mg and Haldol 5 mg at 2:28 AM IM on 6/30/16.

The nurse was summons to the room by the mental health tech at 5:30 AM, 6/30/16, " Pt standing in bathroom removing short tagged lac (laceration) noted above corner of left eye brow with bright red blood..."

The patient was transferred to the acute hospital for a CT scan of his head and sutures to the laceration site 6/30/16 at 6:15 AM.

The patient returned from the emergency room visit 6/30/16 at 10:00 AM, patient very loud stated he needed a bandage to put on foot. "Pt given 2 4x4's and 4 pieces of tape..." The nurse failed to document an assessment of the patient's foot that required a dressing per patient request.

The patient received Percocet 7/1/16 at 10:00 AM for pain in the back level 10 of 10.

The patient complained of severe shoulder and foot pain, noted a 10/10. Treated with Percocet 10 mg by mouth at 10:54 PM on 7/1/16.

The patient complained of severe shoulder pain, rated 10/10. Treated with Percocet 10 mg by mouth 7/2/16 at 4:02 AM.

The patient complained of severe foot pain, rated 10/10. Treated with Tylenol 500 mg by mouth at 5:55 AM on 7/2/16.

The nursing staff failed to assess the patient's continued complaint of foot pain by assessing the foot after medicating the patient for pain twice in less than 8 hours on 7/2/16.

On 7/2/16 at 8:20 PM the nurse documented, " Complained pain all over body rates pain, treated with Percocet 10 mg by mouth and complaint of itching Benadryl 50 mg by mouth antbites all over body. Severe foot pain. Pt right foot has cut on it and swollen. No warmth present to touch. Will report to oncoming nurse for possible consult..."

The nurse failed to assess the cut to the foot, size, drainage, odor or appearance per facility policy.

On 7/3/16 at 2:55 AM the patient complained of right foot pain and requested antibiotic. Advised he must see FMS (Family Medical Service) for assessment. Pain treated with Percocet 10 mg by mouth for pain 10/10.

7/3/16 at 7:45 AM," Upon seeing nurse pt began rambling about snake bites and ant bites on feet. Pt yanked off sock and threw leg up, right foot laceration with no drainage noted on heel and midfoot."

The nurse again failed to assess the wound on the patient's foot although he continues to complaint of pain and has now requested antibiotics for the injury. The nurse failed to consult with the FMS for assessment of a medical complaint by the patient.

On 7/3/16 at 11:15 AM, the patient complained of generalized pain, foot right pain and back pain.

On 7/4/16 at 12:36 AM, " Pt at nurse's station irritable, cursing complain of pain rated at 8 on pain scale in legs and feet. Percocet 10 mg by mouth given..."

On 7/4/16 at 11:30 AM, " Patient complaint of needing something for pain to rub on feet. Continue to have swelling to bilateral feet. Received Percocet this AM and stated he had relieve; bilateral feet washed and dried thoroughly cream applied to help soften the skin. Multiple bites from ants healing with some cracked skin. Has suture to left eyebrow which are due to be removed on tomorrow."

The nurse again failed to document an assessment of the patient's feet 7/4/16.

On 7/4/16 (time illegible), " Patient complain of pain bilateral feet rated pain a 10..."

On 7/4/16 at 10:00 PM, " Patient complained of feet itching from insect bites. Benadryl PRN dose given..."

On 7/5/16 at 7:50 AM, " Agitated, irritable, talking to unseen others...Haldol 10 mg and Ativan 2 mg given IM..."

On 7/5/16 at 2:30 PM, " Patient complained foot pain and was given Percocet 10 mg at 2:00 PM."

On 7/6/16 at 5:15 AM, " Patient complained pain to both feet moderate amount of swelling noted. Percocet tablet one given rates pain 10/10."

On 7/6/16 at 3:30 PM, " Observed pt sitting in day room with sock off of left foot and noted blood coming from wound on...aspect left foot. Patient's feet bilateral are swollen-numerous insect bites to both feet and ankles- numerous old cuts and lacerations to bottom of both feet...clean bloody wound applied telfa pad and took patient to his room."

On 7/6/16 at 3:45 PM, " FMS came on unit while writer was gathering supplies for wound care on patient. Dr...came to room to examine patient."

On 7/6/16 at 4:15 PM, " FMS doctor then cleaned left foot wound with peroxide and normal saline. Removed a foreign object from bottom of left foot after cleaning wounds. Doctor instructed writer to apply TAO (triple antibiotic ointment) and cover wound on left outer aspect of foot with large sterile bandaids..."

MR # 5 was admitted to the hospital 6/28/16 with known injury to bilateral feet but was not seen by a medical doctor until 7/6/16, 8 days after admission. The nurses failed to assess the injuries to his feet although they did note swollen condition and medicated him at least daily for pain in his feet.

In an interview with Employee Identifier (EI) # 3, Nurse Supervisor at 11/17/16 at 7:55 AM, it was confirmed FMS doctors will not necessarily see all of the patients unless the nurse/psychiatrist makes a referral. EI # 3 confirmed the nurses failed to do a complete assessment on PI # 5's feet.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on review of medical records (MR), facility policy and interviews, it was determined the facility failed to ensure each patient's Plan of Care (POC) was complete and up to date to meet the patients behavioral needs. This affected 2 of 9 patients reviewed including Patient Identifier (PI) # 4, # 5 and had the potential to affect all patients in this facility

Findings include:

Policy: Interdisciplinary Plan of Care

V. Policy: " Each patient admitted to ... has an individualized written Interdisciplinary Plan of Care that is based on clinical assessments...

VI. Procedure:
1. On admission, the Admitting Nurse consults with the Admitting Physician and any other staff involved in the intake process...the admitting nurse initiates the Interdisciplinary Plan of Care.

2. Each discipline performing an assessment adds their findings to the needs/diagnosis in the Interdisciplinary Plan on an ongoing basis.

Interdisciplinary Plan of Care Review
1. Interdisciplinary Care Plan reviews are to be completed no later than three (3) days after admission and every 7 days thereafter..."

Policy: Reassessments

V. Policy: " The mutidisciplinary Treatment Team shall continually reassess each patient's status throughout their hospital stay and documentation will reflect all changes in status to include their response to treatment.

VI: Procedure:
a. The Mutidisciplinary Treatment Team shall reassess the overall status of each patient at least every 7 days and complete an update on the Interdisciplinary Care Plan...
c. Significant changes in the patient's condition that would prompt a reassessment are the following changes in:
i. Mental status
ii. Behavioral status
iii. Physical Status
iv. Psychsocial/Life event
v. Functional Status
vi. Discharge Planning"


1. PI # 4 was admitted to the facility 10/6/16 with diagnoses of Schizoaffective Disorder Bipolar Type, Suicidal Ideations and Severe Borderline Personality Disorder.

The Interdisciplinary Progress Notes dated 10/6/16 at 11:20 PM included documentation, " Then she/he started hitting her/his head against the doors, staff attempted to de-escalate patient. Patient is a threat to her-self and not re-directable, place patient in 4 point soft restraints..."

The Interdisciplinary Progress Notes dated 10/6/16 at 11:45 PM included documentation, " Released patient from 4 point restraint criteria was met...patient remains in open safe room."

The Physician's Order form dated 10/8/16 at 8:55 PM included an order, " Place pt in restraints due to being combative with staff."

A face to face evaluation form was in the medical record dated 10/8/16 at 11:05 AM, type of intervention/ seclusion, " Pt in seclusion room from 11:05 AM- 12:00 PM."


The Interdisciplinary Plan of Care_ Adult had the following team members signatures present with the date:
Physician 10/7/16
Licensed Counselor 10/13/16
Recreation Therapist 10/7/16
Registered Nurse 10/6/16
A second Counselor 10/7/16.

The Licensed Counselor failed to sign on to the care plan within 3 days.

Number 12 on the pre-printed care plan is for Restraint and Seclusion. This selection was not marked even though the patient was in restraint and had one episode of seclusion between admission 10/6/16 and 10/8/16.

Psychosocial needs and discharge planning is dated 10/10/16 as is "Other" for an allergic reaction the patient had at a local hospital. The facility failed to up date the care plan to address the needs of the patient who required both restraint and seclusion as interventions for behaviors.

In written questions provided to Employee Identifier (EI) # 3, Nurse Supervisor, 11/16/16 at 4:00 PM the surveyor requested information on updating the care plan regarding the use of restraints and seclusion. In an e-mail from EI # 6, Accrediting Coordinator 11/18/16 at 7:45 AM, it was confirmed there was no further nursing documentation to submit.


2. PI # 5 was admitted to the facility 6/28/16 with diagnoses of Schizophrenia Bipolar Type, Psychosis, Altered Mental Status and living on the streets.

The care plan did address the Infection Potential dated 6/28/16 noting wound to left and right foot although the medical physician failed to see the patient for eight days after admit with an open area to the skin on both feet.

The Interdisciplinary Plan of Care_ Adult had the following team members signatures present with the date:
Physician 7/2/16
Licensed Counselor 7/1/16
Recreation Therapist ___
Registered Nurse 7/1/16
A second Counselor 7/1/16.

The Physician failed to sign on to the care plan within 3 days.

The Interdisciplinary Plan of Care_ Adult had documentation of a seven day review dated 7/11/16. The following team members signatures present with the date:
Physician 7/13/16
Licensed Counselor 7/11/16
Recreation Therapist ___
Registered Nurse 7/11/16
A second Counselor 7/11/16.

The physician again failed to sign the review with the other team members.

On 7/12/16 at 1:42 PM, " Pt continues to rage in hallway yelling, threatening staff...pt at this time required a manual hold to be placed in seclusion ... 2:50 PM pt continues to spit and smear stuff on the window in secluion room remains on secludion."

On 7/12/16 at 3:25 PM, " The FMS documented a manual hold- 1st for injection, 2nd for seclusion no injury to patient."

The Physician's Order Sheet dated 7/12/16 circled Seclusion as the choice for the order. The verbal order was taken by a Registered Nurse at 1:46 PM and marked Restraint for Behavioral Management duration 4 hours.

The facility failed to up date the care plan to address the needs of the patient who required both restraint and seclusion as interventions for behaviors.

In an interview 11/17/16 at 7:55 AM with EI # 3, Nurse Supervisor the above information was confirmed.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations and interviews it was determined the facility failed to maintain and ensure:

1. Patient rooms were well maintained and bathrooms were clean and sanitary.

This had the potential to affect all patients.

The findings include:


During observations of patient areas with Employee Identifier (EI) # 1, Interim Executive Director of Quality, EI # 2, Accreditation Coordinator, and EI # 3, Nurse Supervisor, on 11/15/16 at 8:35 AM, the surveyors identified the following areas of concern:

Geriatric Unit overhead vents were covered with dust in 101, 102, 106 and 107.

Room 103- Shower stall ceiling peeling paint and sheet rock water damaged.

Room 104- Shower stall mildewed, ceiling paint peeling and sheet rock water damaged.

East Unit overhead vents were covered with dust in 215, 216, 217, 218, 219, 223, 224, 225 and 226.

West Unit overhead vents were covered with dust in 202, 203, 204 and 208.

Room 202, 203, 204, 205, 219, 220, 213, 226 shower has thick soap scum on the wall under the controls.

In an interview 11/15/16 at 10:30 AM with EI # 1 and # 6 the above information was confirmed.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on the Emergency Medical Run Report, Medical Record review, Interdisciplinary Plan of Care, Interdisciplinary Plan of Care Review, Interdisciplinary Progress Notes, Policies and Procedures, interviews and Discharge Summary, hospital staff failed to develop a comprehensive discharge plan for Patient Identifier (PI # 9), a patient with a history of multiple overdoses and multiple hospitalization s, to include:

a) Documentation of treatment team meetings

b) Participation of the family in discharge planning

c) Education of the family and

d) Verification of family's acceptance of the patient prior to discharge.

e) A discharge planning evaluation with PI # 9 and her family.

f) The treatment team in a discussion of PI # 9's need for: substance abuse treatment, interventions to encourage PI # 9 to participate in substance abuse treatment, and discuss available treatment options.

g) Education and documentation for PI # 9 and her family regarding discharge expectations.

h) Documentation of any reassessment by PI # 9's primary therapist after 9/16/16 regarding discharge planning and/or discussion by the therapist with PI # 9 about the outcome of the patient's court hearing.



Refer to A 0800, A 0811, A 0812, A 0820 and A 0821 for additional findings.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a review of the Emergency Medical Run Report, Medical Record review, Interdisciplinary Plan of Care, Interdisciplinary Plan of Care Review, Interdisciplinary Progress Notes, Policies and Procedures, interviews and Discharge Summary, hospital staff failed to develop a comprehensive discharge plan for Patient Identifier (PI # 9), a patient with a history of multiple overdoses and multiple hospitalization s, to include documentation of treatment team meetings, participation of the family in discharge planning, education of the family and verification of family's acceptance of the patient prior to discharge. This deficient practice affected PI # 9, one of nine sampled patients, and had the potential to affect all patients admitted to the psychiatric unit.

Findings Include:

1). Emergency Medical Run Report:

A review of the Emergency Medical Run Report revealed PI # 9 was found unresponsive, cyanotic (bluish discoloration of skin and mucous membranes due to not enough oxygen in the blood, www.medicinenet.com) and lying on the floor at home on 9/12/16.
Respiratory rate was four breaths per minute and irregular. Supportive ventilation was provided and Narcan was administered (Narcan: medication that counteracts the life-threatening effects of opioid overdose, www.narcan.com). Family member stated possible Heroin overdose.
PI # 9 vomited about six times and was transported via ambulance to the emergency room .

2. Medical Record Review:

Admission Nursing Assessment:

Patient Identifier (PI) # 9 was admitted on [DATE] at 12:21 PM following an accidental overdose on Heroin. The Nursing Admission Suicide Risk Assessment score was 31 (Moderate risk).

Chief Complaint (Patient's own words): " I don't want to do this anymore."

Mood: Anxious and labile (mood state in which a person experiences wild, uncontrolled mood swings, www.reference.com).

Cognition: Easily distracted.

Thought Process: Racing thoughts, helplessness, worthlessness and anxiety.

Thought Content: Paranoia, Suicidal ideation.

Insight: Fair.

Judgement: Fair.

Memory (recent and remote): fair.

Patient Stressors/Weaknesses: Family difficulty, Substance abuse, Non-compliance with treatment and medications, legal problems.

Nursing Summary Includes: ...Alert and oriented x three. Appearance dishevel, unkept...Anxious, tearful and sad...Admits to being a heroin addict who has been in treatment four times...Denies wanting treatment for drug abuse.

"When asked if suicidal, she (PI # 9) denies...When questioned if she attempted to kill herself before she states, "Everytime I shoot up."

Contacted doctor for orders...15 Minute Observations, "Crisis Orders" and Opiate Protocol.


History and Physical 9/14/16: Psychiatric Evaluation Includes:

History of Present Illness: [AGE] year old with substantial heroin dependence is admitted after overdose of heroin. She is depressed, overwhelmed and could not contract for safety.

Past Medical History: Hepatitis C.

Past Psychiatric History: She has been on Prozac and Gabapentin (reason for use not documented) with reasonable results in the past although they are not working now.

Substance Abuse: She is using heroin on an excessive daily basis.

Mental Status Examination Includes: Alert and oriented x 3. She is highly impulsive and irritable. She endorses suicidal ideation with plan to overdose if things do not change.

"There is a question as to whether or not she told her mother that she wanted to kill herself; the mother states this is true. The patient (PI # 9) is equivocal (noncommittal, Google). She does admit that she has had thought of suicidal and could not contract for safety."

Admission Diagnoses:
1. Opiate Dependence.
2. Opiate Withdrawal.
3. Major Depressive Disorder.

Plan:
1. Admit to (Name of Psychiatric Hospital).
2. Individual and group therapy.
3. Will detox.
4. Start Celexa (medication) for depression.


Progress Notes (Psychiatrist):

9/15/16 at 1:30 PM:

She (PI # 9 ) is still agitated. Distant and very labile (emotions that are easily aroused and freely expressed, and that tend to alter quickly and spontaneously; emotionally unstable, Google).

Plan: Hearing tomorrow.

General Appearance: Unkempt/disheveled (untidy; disordered, google.com).

Behavior: Uncooperative, guarded, restless, inattentive.

Affect: Labile.

Thought Processes: Circumstantial, unclear and tangential (diverging from a previous course; erratic. google.com)

Safety: Suicidal ideations with plan for overdose.

Insight / Judgement: Poor.

Cognition: Fair. (Cognition: mental process of acquiring knowledge and understanding through thought, experience, and the senses, google.com).


9/16/16 at 12:50 PM:

Still depressed and sad.

Plan: Refer to rehab (rehabilitation for substance dependence).

General Appearance: Unkempt/disheveled.

Behavior: Guarded, restless.

Affect: Sad, constricted, flat, depressed.

Mood: Per patient account: Sad.

Thought Processes: Circumstantial, unclear and tangential.

Safety: Suicidal ideations with plan for overdose.

Insight / Judgement: Poor.

Cognition: Fair.


9/17/16 at ? (unable to read time as documented):

Plan: Patient (PI # 9) under 30 day continuance (probate court decision).

Affect: Sad, depressed.

Mood: Per patient account: "Bad."

Thought Processes: Coherent, logical.

Safety: Commits to safety. No plan.

Insight / Judgement Cognition: Fair.


9/18/16 at 4:00 PM:

Plan: Continue detox. Refer to long term rehabilitation.

Behavior: Cooperative and engaging.

Affect: Worried, sad, anxious, depressed.

Thought Processes: Clear, coherent.

Safety: Commits to safety. No plan.

Insight / Judgement: Fair.

Cognition: (not documented).


Psychosocial Assessment:

9/15/16 at 12:08 PM by Licensed Counselor, National Certified Counselor Employee Identifier (EI) # 9:

Chief Complaint (patient's own words): " I overdosed on Heroin and can't keep living like this."

Information gathered from:
Patient report
Past record

Precipitating event: Patient is court ordered petition.

Suicidal ideation: Patient denies.

Behavior:
Poor impulse control: Current and history of.

Major Life Areas:
Loss of interest in activities: Current and history of.

Anxiety:
Restlessness: Current and history of.

Patient continues to have issue with Heroin addictions.

Substance Abuse:
Has the patient suffered from problems with substance abuse in the past 12 months? Yes.
Opiate: Age of onset: Not documented.
Duration: "Ongoing."
Intensity: Not documented.
* (Previous medical record was available)

Consequences of abuse of any of the previously listed substances: No documentation.

Past Treatment:
Multiple psychiatric hospitalization s (most recent: June 2016).
Previous treatment for substance abuse: No dates or description documented.

Family History of Mental Illness: Father

Current Living/Social:

Patient currently lives with: Father.

Patient's plan for living at discharge: Unknown; Court Ordered Petition.

Current income: None.

Collateral Contact: 9/14/16 at 4:28 PM - Documented by Court Liason/Employee Identifier (EI # 8):

Name of contact: Name of PI # 9's mother
Relationship to patient: Petitioner
Court Petitioned: "Yes (Petitioner to be contacted, no consent needed - no information given)."

Notes: "Patient (PI # 9) was living with her father who is always depressed, stays in bed and is on pain pills. Patient's mom has patient's two year old and the child will be removed if patient stays there. Patient has used Heroin two years and "Meth" past 3 -6 months (Meth = Methamphetamine, an extremely addictive stimulant drug that is chemically similar to amphetamine, www.drugabuse.gov/publications/drugfacts/
methamphetamine) Patient's memory problem started last Thursday (7 days ago). Patient can remember numbers and peoples names, but can't remember talking to them. Went on job interview and didn't remember. Keeps calling Mom and can't remember that she just called. Patient got a different drug and the memory thing is new. (Name of another hospital) did CT (Computerized Tomography) which was normal, but Mom says something is wrong. Mom reports if she (PI # 9) is not locked up she will be back on the streets with this bad memory problem." Patient had an appointment with (name of drug treatment provider) on Monday... as mom was driving to appointment patient fought her - got money out of her (Mom's) purse and took off to get drugs..."

3). Interdisciplinary Plan of Care - Adult 9/13/16: (Initiated by admitting RN):

Patient Limitations:
- Non-compliance with treatment
- Uses drugs

* Although a selection of Long Term Goals are listed on the form, none were documented.

Need/Diagnosis: Psychosocial needs and discharge planning dated 9/13/16: -Homeless
- Expected Outcome:
...Discharge plan will be in place.

Expected outcomes (available choices pre-printed on form, but NOT selected:
- Patient / family will verbalize understanding of discharge plan.
- Patient/ family will be familiarized with community resources as needed.

Target Date: Ongoing.

Intervention: Interventions (available choices pre-printed on form, but NOT selected:
- Therapy staff will work with patient / family.
- Therapy staff will conduct family session to deal with issues of discharge as ordered by physician.

4). Interdisciplinary Plan of Care Review: 9/16/16 at 1:10 PM:

Review of needs/Diagnosis: 3 Day Review (PI # 9 admitted [DATE])

...2. Safety issues: "Good progress."

4. Withdrawal: "Minimal progress."

6. Noncompliance: "Good progress."

13. Discharge Planning: "Minimal progress."


Review of Long Term Goals: "Patient is court ordered petitioned. The outcome of her hearing will determine where patient will go upon discharge.

Family...has participated in treatment planning: "No."

No additional Interdisciplinary Plan of Care notes/documentation was found in PI # 9's medical record.

5). Interdisciplinary Progress Note: 9/16/16 at 3:45 PM

Discipline: Th (Therapy): "Patient was not present for tx (treatment team) meeting, due to be asleep. However, once pt. (patient) awakened update of pt's IPOC (Individual Plan of Care) was conducted with her. Patient missed her court hearing today as well due to being asleep. Patient...has minimal progress in problems...13." (Discharge Planning). "Therapist will continue to follow up."

There is no additional documentation by the therapist in the Interdisciplinary Progress Notes.

Interdisciplinary Progress Note: 9/19/16 at 2:33 PM by Nursing:

"Patient discharge home via taxi..."

Interdisciplinary Progress Note: 9/19/16 at 2:50 PM by Social Work:

"Called patient's Mom per her (PI # 9's) request. Mom was most upset the patient had been discharged . She still is wanting patient locked up for 3 months...It has been explained to Mom multiple times, by multiple staff, including (name of Psychiatrist), the patient has a drug problem and does not want treatment."

6). Policies and Procedures:

a). Psychosocial Assessment CS.022

Revision Date: 4/2015

Elements to be included in the Psychosocial Assessment:

...5. Family/Peer support systems are identified by interviews with family members...

7. Patient family... educational needs...


b). Discharge upon Completion of Treatment: CS.050

Revision Date: 1/2015

...V. Policy: Patients will be discharged ...when deemed clinically appropriate by the attending physician and the interdisciplinary treatment team...

C. Social Worker (SW) /Therapist Responsibilities:

1. Discharge plans are coordinated by the SW / Therapist per the treatment team.


7). Interviews

Interview on 11/14/16 at 1:30 PM with Family Identifier (FI) # 1:

FI # 1 stated she was worried about a new problem: PI # 9's memory.
According to FI # 1, PI # 9 called her approximately five times in 20 minutes and could not recall her actions. FI # 1 took the patient for a CT scan, but it was normal. FI # 1 expressed concern that PI # 9 had been hit on the head during a drug binge or given an unknown drug.

On 9/12/16 PI # 9 overdosed on heroin and told FI # 1 that she wished she had died . PI # 9 was admitted on [DATE] after a Heroin overdose. According to FI # 1, the psychiatrist (EI # 7) called her on 9/13/16 and said he would not recommend commitment because PI # 9 needed long term treatment for drug abuse.

FI # 1 said she told EI # 8 (Court Liason) about PI # 9's memory problem at the beginning of her hospitalization on the psychiatric unit. On Monday (9/19/16), FI # 1 said she received a telephone call from Employee Identifier /# 8 informing her that PI # 9 was being discharged to her Dad's home. "I (FI # 1) said no. Her (PI # 9) Dad had refused. He would not answer his phone." FI # 1 said she told EI # 8 that she refused to pick up the patient (PI # 9). Five minutes later EI # 8 called back and said PI # 9 had already left the hospital in a cab.

FI # 1 said she stressed her concern about PI # 9's memory problem to staff at the (name of psychiatric unit) and at the hearing. PI # 9's memory loss put her in increased danger. According to FI # 1, the patient had overdosed three to four times this year.

FI # 1 stated after the patient was discharged from the psychiatric unit on 9/19/16, PI # 9 stayed with her Dad until 9/20/16 until FI # 1 took PI # 9 for an "emergency" assessment at a drug treatment program (recommended by a psychiatrist at the drug treatment program). PI # 9 was admitted to a Transition Home while waiting for an "emergency" rehabilitation bed, but was discharged for m the home after she informed staff she was positive for Hepatitis C.

PI # 9 returned to her father's home. She (PI # 9) was found unresponsive on 9/22/16 and expired. FI # 1 reported the autopsy results are not available.


Interview on 11/15/16 at 9:00 AM with Attending Psychiatrist / Medical Doctor, Employee Identifier (EI) # 7:

According to EI # 7, the patient's (PI # 9) father agreed to let her come to his home after discharge. PI # 9 agreed to go to (name of drug treatment provider). "It is hospital policy (psychiatric unit) to verify someone is going to allow the patient to show up when discharged ."

Regarding the 30 day continuance granted by the judge, EI # 7 said the patient can be released from the hospital at the physician's discretion. PI # 9's primary diagnosis was Opiate Dependence. A patient cannot be committed by the court for treatment of drug abuse. PI # 9 refused Long Term Drug Treatment, but agreed to outpatient treatment.


Interview on 11/15/16 at 1:10 PM with Court Liason, LBSW ( Licensed Baccalaureate Social Work), EI # 8:

According to EI # 8, PI # 9 was admitted "under a petition" by her mom. This means the patient could not leave the hospital before the hearing date on 9/16/16. Reportedly the attending psychiatrist talked to PI # 9's mom prior to the hearing and decided to ask for a continuance. A 30 day continuance was granted on 9/16/16 and means the patient must follow the physician's recommendation for 30 days (until 10/14/16).

EI # 8 explained the court process: After discharge, if PI # 9 failed to follow the psychiatrist's treatment recommendations, her mom could notify probate court. PI # 9 could have been picked up and returned to the hospital based on the court's decision. Probate court does not follow the patient. The court is only aware of a problem if they are notified by family.
*No documentation of a conversation between the psychiatrist and PI # 9's mother was found in the medical record.

Interview on 11/16/16 at 10:45 AM with Treatment Manager, LPC (Licensed Professional Counselor) / EI # 4, Administrator / EI # 2, and Nurse Supervisor / EI # 3:

EI # 4 stated the treatment team met on 9/19/16 and talked with PI # 9 and tried to convince her to go to treatment. He verified there is no documentation in P # 9's medical record regarding a treatment team meeting on 9/19/16. EI # 4 stated the primary therapist is responsible for finding discharge placement. EI # 4 verified there is no note documented in the record by the therapist regarding specific discharge plans for PI # 9.


Interview on 11/16/16 at 1:10 PM with Treatment Manager, LPC (Licensed Professional Counselor), EI # 4:

EI # 4 was asked if the psychiatrist is supposed to attend treatment team and he said, "Theoretically. But he wasn't." The surveyor provided a copy of PI # 9's medical record to EI # 4. The surveyor asked EI # 4 if there was any other documentation about PI # 9's discharge in the record. EI # 4 replied, "I don't see anything. It should be there." According to EI # 4, usually a note is written by the therapist or the court liason documenting details about where the patient is going and a call to the significant other or family as allowed by the patient. EI # 4 stated the court liason's telephone call to PI # 9's mother at discharge was a "courtesy" call. The surveyor asked EI # 4 to state his conclusion about the lack of documentation regarding discharge planning and he said, "Haven't found the information. It is usually scanned in." EI # 4 stated PI # 9's treatment team met on 9/19/16, the day of discharge, but there was no documentation in the medical record. No additional documentation was provided by staff.

Interview on 11/16/16 at 2:15 PM with RN (Registered Nurse) Day Shift Supervisor / EI # 3:

EI # 3 stated the therapist gathers information as to where a patient will be discharged . This information should be discussed during treatment team meetings.

Interview on 11/17/16 at 9:05 AM with Mental Health Therapist, LPC, Nationally Certified Counselor/ EI # 9:

EI # 9 was asked if she spoke with PI # 9's father and she said, "No, I didn't. I wasn't necessarily involved in her (PI # 9's) discharge. Didn't say (other staff) where PI # 9 was going. I was told to get a cab voucher (for PI # 9) by the nurses." EI # 9 said she was called to the nurses' station.

The surveyor asked EI # 9 whose responsibility is it to determine where a patient is discharged . EI # 9 said, "Usually the therapist." The surveyor asked EI # 9 if it was her responsibility for planning PI # 9's discharge. EI # 9 replied, " I imagine so." EI # 9 said she found out about PI # 9's discharge on Monday (9/19/16) when she came to the unit and was told the patient was discharging to her dad's home and was asked to get a cab for the patient.

Interview on 11/17/16 at 9:42 AM with Staff RN / EI # 10:

EI # 10 was asked to clarify her documentation in the admission summary: "When asked if suicidal, she (PI # 9) denies...When questioned if she attempted to kill herself before she states, "Everytime I shoot up." EI # 10 verified the documentation was correct. At the time of discharge PI # 9 said she did not want treatment, refused substance abuse treatment and said she wanted to go home. EI # 10 said PI # 9's Dad was called, but staff was unable to talk with him. A cab was called to transport PI # 9 to her Dad's home because she was unable to obtain transportation.

EI # 10 said the treatment team is involved in discharge planning, but therapist is primarily responsible for ensuring the discharge plan is adequate and providing feedback to the psychiatrist.


8). Discharge Summary: 9/19/16

Discharge Diagnoses:

Axis 1: Major Depressive Order
Opiate Dependence
Opiate Withdrawal

Axis 11: Borderline Personality Disorder.

Axis 111: Hepatitis C.

Followup Recommendations:

Local healthcare Provider, Mental Health Center and Name of a center that primarily focuses on substance abuse services.

Reason for Admission:

"The patient (PI # 9) came in under a petition (A procedure whereby the Probate Court orders mental health services in either an outpatient or inpatient setting. The purpose of involuntary commitment is to provide psychiatric treatment for mentally ill individuals who have become a danger to themselves...and are refusing voluntary treatment. A person cannot be committed due to a drug or alcohol problem, http://www.mc-ala.org).
She (PI # 9) had again been using heroin..."


Hospital Course:

"The patient was clearly having substantial drug use, which was a big factor in her issues. She (PI # 9) was treated for her mood disorder, but clearly had substantial polysubstance issues... We recommended long term rehab (rehabilitation); she refused out and out. She was given a 30 day continuance, but clearly had met inpatient criteria for stability. She was discharged at this point...on Celexa (antidepressant), with referral to (Name of a center that primarily focuses on substance abuse services)."


Conclusion: The Treatment Team failed to thoroughly address and discuss PI # 9's discharge plan with the patient and/or her family. The discharge was abrupt as evidenced by lack of specific documentation about the patient's discharge prior to the day of discharge (9/19/16) and the statement of the primary therapist who said she was not aware of the patient's discharge until the time of discharge when she was asked to obtain transportation for PI # 9. Staff also failed to contact PI # 9's Father prior to discharge and / or at discharge to confirm his willingness to accept the patient. Although PI # 9's diagnosis of Hepatitis C was known to staff, staff referred her to a program that does not accept Hepatitis positive patients. Staff was responsible for ensuring the resources they recommended for PI # 9 were appropriate.
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
Based on a review of the Emergency Medical Run Report, Medical Record review, Interdisciplinary Plan of Care, Interdisciplinary Plan of Care Review, Interdisciplinary Progress Notes, Policies and Procedures, interviews and Discharge Summary, hospital staff failed to provide and document discussion of the discharge planning evaluation with PI # 9 and her family. There was no documentation to indicate PI # 9's family was involved and or invited to participate in the patient's discharge planning. Specifically, the Interdisciplinary Plan of Care Review documented the family has not participated in treatment planning. There was no explanation about the family being asked to be involved in PI # 9's discharge planning. This deficient practice affected PI # 9, one of nine sampled patients, and had the potential to affect all patients admitted to the psychiatric unit.


Findings Include:

Please refer to A 0800.
VIOLATION: DISCHARGE PLANNING Tag No: A0812
Based on a review of the Emergency Medical Run Report, Medical Record review, Interdisciplinary Plan of Care, Interdisciplinary Plan of Care Review, Interdisciplinary Progress Notes, Policies and Procedures, interviews and Discharge Summary, hospital staff failed to include all of the treatment team in a discussion of PI # 9's need for: substance abuse treatment, interventions to encourage PI # 9 to participate in substance abuse treatment based on her known history of noncompliance and discussion and documentation of available treatment options, treatment team members failed to develop a comprehensive discharge plan for Patient Identifier (PI # 9). This deficient practice affected PI # 9, one of nine sampled patients, and had the potential to affect all patients admitted to the psychiatric unit.


Findings Include:

Refer to A0800.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on a review of the Emergency Medical Run Report, Medical Record review, Interdisciplinary Plan of Care, Interdisciplinary Plan of Care Review, Interdisciplinary Progress Notes, Policies and Procedures, interviews and Discharge Summary, hospital staff failed to develop a comprehensive discharge plan for Patient Identifier (PI # 9), a patient with a history of multiple overdoses and multiple psychiatric hospitalization s, to include education and documentation for PI # 9 and her family regarding discharge expectations. This deficient practice affected PI # 9, one of nine sampled patients, and had the potential to affect all patients admitted to the psychiatric unit.

Findings Include:

Refer to A 0800.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
Based on a review of the Emergency Medical Run Report, Medical Record review, Interdisciplinary Plan of Care, Interdisciplinary Plan of Care Review, Interdisciplinary Progress Notes, Policies and Procedures, interviews and Discharge Summary, hospital staff failed to develop a provide and/or document comprehensive discharge plan for Patient Identifier (PI # 9), a patient with a history of multiple overdoses and multiple hospitalization s, to include documentation of treatment team meetings, participation of the family in discharge planning, education of the family and verification of family's acceptance of the patient prior to discharge. Specifically, there was no documentation of reassessment by PI # 9's primary therapist after 9/16/16 regarding discharge planning and/or discussion by the therapist with PI # 9 about the outcome of the patient's court hearing. "Minimal progress" was documented as the update for PI # 9's discharge planning needs by the therapist on the Interdisciplinary Plan of Care Review dated 9/16/16. This deficient practice affected PI # 9, one of nine sampled patients, and had the potential to affect all patients admitted to the psychiatric unit.

Findings Include:

Refer to A 0800.