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|GEISINGER MEDICAL CENTER||100 NORTH ACADEMY AVENUE DANVILLE, PA 17822||May 24, 2016|
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide care in an emotionally safe environment by utilizing room restriction without an order for one of 11 medical records reviewed (MR1).
Review on May 20, 2016, of facility policy "Patient Rights and Responsibilities," last reviewed December 19, 2015, revealed "Purpose: To ensure that patients are informed of their rights, which are referred to in the Patient Rights and Responsibilities brochure. Policy: Patients will receive information regarding their patient rights and responsibilities during an outpatient encounter and prior to admission. Geisinger personnel will be available to answer questions related to patient rights and responsibilities."
Review on May 20, 2016, of facility brochure "Patient Rights and Responsibilities October 2015," revealed "... Patient Rights: ... 1. A patient has the right to respectful care given by competent personnel. ... 24. A patient has the right to participate in the development and implementation of his or her plan of care. ... 30. A patient has the right to receive care in a safe setting. ... 34. A patient has a right to be free from seclusion and restraints of any form for behavioral management imposed as a means of coercion, discipline, convenience or retaliation by staff. ... 36. A patient has the right to an environment that preserves dignity and contributes to a positive self-image. 37. A patient has a right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation, or harassment. ..."
Review on May 20, 2016, of facility policy "Policy 12.06 Formulation of the Multidisciplinary Treatment Plan," last reviewed February 10, 2016, revealed "Formulation of Multidisciplinary Treatment Plans Formulation of Multidisciplinary Treatment Plan for Adolescent Patients The treatment plan is initiated by a RN within 8 hours of admission and documented on the multidisciplinary treatment plan form. The treatment team (may be comprised of the psychiatrist, therapist, psychologist, mid-level provider, RN [Registered Nurse], caseworker, OT [Occupational Therapist], COTA [Certified Occupational Therapist Assistant], recreational therapist, activities coordinator) will formulate the treatment plan and review it within 72 hours after admission. It is problem-oriented, based on initial assessment of patient problems, strengths and includes medical co-morbidities. The RN assigned/co-assigned to the patient is responsible for the elaboration of the care plan daily and update/documentation of the plan by the team in each treatment team meeting. A measurable short-term goal is written for each identified problem. A target date is determined for each short-term goal. As the short-term goal is achieved or discontinued, GA-D (goal achieved-discontinue) is added. Nursing/treatment team interventions or methods to reach the goal and the responsible person for each are documented on the plan. A discharge goal is documented on the multidisciplinary treatment plan. ... Subsequent changes and reassessments in the treatment plan will be made as needed when the patient's case is reviewed in treatment team on a daily basis. ..."
Review on May 20, 2016, of facility policy "Policy 12E Adolescent Guidelines (Danville campus only)," last reviewed February 10, 2016, revealed "Purpose: The purpose of this policy is ... 1. All patients 17 years or younger or above [AGE] and currently in high school are considered adolescents, and will be placed on B1 level upon admission. Your treatment team will evaluate and advance your privilege level as progress and behavior warrants. ... 12. Adolescent Privilege Level System Level B1 Immediate family visits only (parent/guardians/grandparents and siblings accompanied by the parent/guardian/grandparent) Level B2 Recreation Room/Deck Privileges Video game access To reach level B2: Complete Social History, Physical Exam, and any Labs or Psychological Testing that is ordered. Attend Activities as prescribed by Treatment Team No Infractions for 24 Hours Maintain appropriate behavior and demonstrate progress in treatment. If you choose not to follow these guidelines: 1st Offense: You will be given 30 minutes time out in your room and you will be ineligible for a level increase for 24 hours. 2nd Offense: 30 minute time out in your room and return to Level B1. You are still expected to attend and participate in all therapeutic activities as designated. ..."
Review on May 20, 2016, of facility policy "Policy 12.26 Guidelines for Inpatient Adolescent (17 Years and Under) Care (Danville campus only)," last reviewed February 10, 2016, revealed "Guidelines For Inpatient Adolescent (17 Years and Under) Care 1. All patients 17 and under will be on an adolescent privilege level. See Policy 12E for specific information regarding adolescent guidelines. a. Any level changes are to be determined by the Treatment Team. ..."
Review on May 20, 2016, of facility policy "Policy 12D Observation levels," last reviewed February 10, 2016, revealed "Observation Levels Level B - Close Observation ... 2. You may or may not reside in a room that can be monitored at all times by staff. This room may or may not be locked depending on your condition. 3. When you are out of your room you may be restricted to the lounge area, and must inform staff if you need to leave this area. 4. You can participate in unit activities at the staff's discretion. 5. You may use the recreation room and deck only when accompanied by a staff person. This will occur at the availability of the staff. ... 6. The treatment team will determine visits and phone calls. ..."
Review on May 20, 2016, of MR1 revealed the following:
The patient was admitted on [DATE], for depression and suicidal ideation. The Multidisciplinary Treatment Plan for Psychiatry revealed the presenting problems listed as suicidal ideation and cutting self. The discharge goal for MR1 was to verbalize improvement in mood and an absence of thought of self harm. The methods to reach the goal included assessments, medications, activities, family meeting on May 6, 2016, Level B - close observation on May 13, 2016, Observation level B1 and discharge to home on May 16, 2016. There was no documentation in the treatment plan for the use of room restriction. There was no practitioner order for room restriction.
A nursing note written at 8:34 PM on May 12, 2016, stated MR1 was restricted to their room except for meals. The nursing note at 6:41 PM on May 13, 2016, revealed MR1 remained on room restriction.
A therapy note written at 8:15 AM on May 11, 2016, revealed MR1 was to return to their room after attending groups and meals per instruction from CF2. A therapy note written at 17:07 PM on May 13, 2016, revealed MR1 stated their goal was to convince their doctor staying in their room was not helpful.
A progress note written at 4:43 PM on May 11, 2016, by CF2 revealed they were concerned MR1 was being manipulative, had a hidden agenda, and was using the behavioral health unit to avoid unpleasant things. Further review of this note revealed MR1 was told they would be in a private room with increased supervision until MR1 was less suicidal.
A progress note written at 1:37 PM on May 13, 2016, by CF1 revealed MR1 was on room restriction except for meals and groups. MR1 was given writing assignments to complete.
A progress note written at 11:27 AM on May 15, 2016, by OTH1 revealed MR1 was not displaying any suicidal ideations and was requesting to come off of room restrictions.
A progress note written at 8:07 AM on May 16, 2016, by OTH2 revealed MR1 was unable to attend treatments due to room restriction.
Interview at approximately 2:30 PM on May 20, 2016, with EMP1 confirmed there was no documentation in MR1's treatment plan for the use of room restriction, and there was no written order for room restriction. EMP1 also confirmed the contents of the nursing notes of May 12 and 13, 2016. The contents of the therapy progress notes of May 11 and 13, 2016, was confirmed by EMP1. The progress notes written by CF1, CF2, OTH1, and OTH2 were also confirmed by EMP1.
Interview with PF1 at 11:00 AM on May 20, 2016, revealed PF1 worked on May 14, 15 and 16, 2016. PF1 confirmed MR1 was on room restriction except for meals, groups and family visits for at least three days. PF1 stated the direction for room restriction was given verbally by a member of the adolescent psychiatry team and could only be discontinued by a member of this team. PF1 confirmed there was no written policy for the use of room restriction.
Interview with PF3 at 11:28 AM on May 20, 2016, revealed PF3 worked with MR1 on May 11, 2016. PF3 stated the direction for room restriction was not always written as an order. PF3 stated the direction for room restriction was passed on to the oncoming nurse in the nursing shift report. PF3 confirmed MR1's treatment plan did not include the use of room restriction or criteria for removal of the room restriction.
Interview with PF6 at 11:55 AM on May 20, 2016, revealed PF6 worked with MR1 during this admission. PF6 stated this was MR1's first inpatient behavioral health admission. PF6 stated MR1 made a comment they needed to be in the hospital for a long time. PF6 stated MR1 needed the room restriction for safety reasons.
Interview with PF8 at 12:13 PM on May 20, 2016, revealed they worked on May 15, 2016, when MR1 was on room restriction. PF8 stated they understood room restriction meant the patient must remain in their room except for meals and groups. PF8 stated there was no written order for the room restriction. PF8 learned about the room restriction during the nursing shift report.
Interview with CF1 at approximately 1:15 PM on May 20, 2016, revealed they covered the adolescent inpatients on May 13, 2016. CF1 met with MR1 on May 13, 2016, and gave MR1 writing tasks to complete while they were on room restriction. CF1 stated room restriction was utilized with adolescent patients who appeared to be manipulative and not utilizing their admission to work on their behavioral issues. CF1 explained they write orders related to behavioral issues with the adolescent patients.
Interview with PF9 at 2:20 PM on May 20, 2016, revealed they were aware MR1 was placed on room restriction. PF9 understood the reason for the room restriction was for patient safety. PF9 stated MR1 was to be in their room except for meals, groups and telephone use. PF9 stated MR1 was to think about the issues keeping them from going home. PF9 confirmed there was no written criteria for removal of the room restriction.
Interview with PF4 at 2:35 PM on May 20, 2016, revealed they worked with MR1 on May 15, 2016. PF4 stated MR1 was on room restriction to work on their goals and for time for introspection. PF4 stated the adolescent treatment team decides when the room restriction can be discontinued. PF4 stated the adolescent treatment team does not work on the weekend.
Interview with PF2 at 2:55 PM on May 20, 2016, revealed they worked with MR1 on May 13, 14 and 15, 2016. PF2 stated MR1 was on room restriction on these days.
Interview with CF2 at 3:10 PM on May 20, 2016, revealed they cared for MR1 during their May 5, 2016, admission. CF2 stated MR1 verbalized they wanted to stay in the hospital for one month and did not show interest in working on their coping skills. CF2 instructed MR1 to stay in their room and work on their issues. CF2 stated they felt the room restriction would help MR1 focus on their issues.
Interview with PF5 at 9:00 AM on May 23, 2016, revealed they worked with MR1. PF5 stated there was no written order for the room restriction for MR1. On May 16, 2016, PF5 asked OTH3 if MR1's room restriction could be stopped. PF5 stated that OTH3 said no, the room restriction was the consequence for manipulative behavior. PF5 stated room restriction was utilized infrequently. PF5 also stated there was usually a written order for room restriction.
Interview with OTH2 at 9:00 AM on May 23, 2016, revealed they cared for MR1 during their May 5, 2016, admission. OTH2 stated they were informed by CF1 about MR1's room restriction. OTH2 stated the room restriction was due to MR1's manipulative behavior. EMP2 confirmed MR1 was discharged on [DATE].