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.

HOLLY HILL MENTAL HEALTH SERVICES 3019 FALSTAFF RD RALEIGH, NC March 15, 2013
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, observation, and staff interview the hospital's nursing staff failed to incorporate the Behavioral Modification Plan (BMP) in the Master Treatment Care Plan (MTP) for 5 of 5 patients (Patient's #1, 3, 4, 14 & 28).

The findings include:

Review of current hospital policy Master Treatment Plan (MTP) reviewed 08/11 revealed "The Master Treatment Plan is initiated by the RN (registered nurse) within 24 hours of admission ....Problems/Behavioral: The RN ...writes a sentence description of the patient's behavior that demonstrates the reasons the patient has the diagnoses and needs hospitalization and initiate a Treatment Problem Sheet for each problem ...Additional Information: treatment team members or patients may write information in the comments section relevant to treatment ...Problem Sheets ...nursing may initiate additional psychiatric or substance abuse problem sheets as other problems are identified ...Intervention Strategy:...each discipline on the treatment team is responsible for picking an intervention that will enable the patient to achieve his/her objectives ...Master Treatment Plan Update: The MTP is reviewed at a minimum of every seven days during Treatment Team Meeting. The MTP Update is completed by treatment team members during Treatment Team Meeting. The MTP is also used for individualized treatment planning (ITP) beyond the original plan ...Nursing and/or social service staff write and circle any new problem identified by treatment team members since the initiation of the MTP ...if a new problem is identified, a new problem sheet must be filled out ... "

Review of the hospital policy Behavioral Management Procedures (Latency - Adolescent) dated 09/12 revealed ... it is the policy of (named facility) to provide appropriate clinical interventions for managing and changing maladaptive or problem behavior ... 3. ...e. the BMP is part of the multidisciplinary treatment plan f. all staff involved in the implementation of the plan will be familiar with the program, its goals, objectives, and interventions. This will occur through regularly scheduled staffing and specifically called staffing ...g. placement of a patient on unit restrictions requires a Physician Order and supporting nursing documentation in the progress notes."

1. Open medical record review on 03/14/2013 of patient #1 revealed an eleven year old male admitted on [DATE] with a diagnosis of anxiety, depression, agitation and suicidal ideation. Review of the chart revealed a typed memo dated 02/02/2013: "To: 2 NB (nursing unit) Nursing Staff ... From: (Physician #1); Subject: Behavioral Modification Plan for (patient #1)". The memo contained a list of activities and restrictions for patient #1. Review of the Master Treatment Plan (MTP) and Problem List dated 01/30/2013 revealed "Active Problem List:... #1 self harm; #2 violence/aggression." Continued review of the MTP Problem #1 Self Harm under Intervention Strategy Physician Column revealed no documentation of an intervention strategy. Continued review of the MTP Problem #2 Violence/Aggression under Intervention Strategy Physician Column revealed no documentation of an intervention strategy. Continued review of the MTP Problem Violence/Aggression revealed an update on 02/01/2013 by the RN under "Problem: Self Harm Short Term Individualized Objectives patient to develop 1-2 + (positive) way to prevent self harm". Continued review of the MTP Update on 02/07/2013, 02/13/2013, 02/20/2013, 02/27/2013, and 03/06/2013 revealed no documentation of the BMP.

Interview on 03/13/2013 at 1600 with Physician #1 revealed "BMP is ordered by the physician. I would expect the BMP to be on the care plan".

Interview on 03/13/2013 at 1640 with Nurse #1 revealed "the BMP should be documented on the Master Treatment Plan under behavioral problem".

Interview on 03/14/2013 at 1050 with Nursing Administrative Staff revealed "the BMP is physician driven during team conferences then a physician order is written to implement the BMP ...my expectation would be the BMP would be documented in the progress notes and noted in the Treatment Plan and correspond with the treatment goals". Continued interview revealed "the BMP is not included in the Treatment Plan on patient #1's chart and there is no progress note indicating the patient had a BMP in place."

2. Open medical record review on 03/15/2013 of patient #14 revealed a seventeen year old male admitted on [DATE] with a diagnosis of Mood Disorder, Homicidal Ideation, and Polysubstance Abuse. Review of the chart revealed a typed memo date 03/12/2013 "To: 2 East Nursing Staff ... From: (Physician #3) with Subject: Behavioral Modification Plan for (patient #14)". Review of the Physician's Order on 03/12/2013 revealed an order for "place on BMP". Review of the Master Treatment Plan (MTP) and Problem List dated 02/04/2013 revealed "Active Problem List:... #1 potential for violence"; Continued review of the MTP Physician Column revealed no documentation of an intervention strategy. Continued review of the MTP Problem Violence/Aggression revealed updates on 02/27/2013, 03/06/2013, and 03/30/2013 with no documentation of a BMP implemented.

Interview on 03/14/2013 at 1050 with Nursing Administrative Staff revealed "the BMP is physician driven during team conferences and a physician order is needed to implement the BMP...my expectation would be the BMP would be documented in the progress notes and noted in the Treatment Plan and correspond with the treatment goals." Continued interview revealed "the BMP is not included in the Treatment Plan on patient #14 and there is no progress note indicating the patient had a BMP in place."

3. Closed medical record review on 03/13/2013 of patient #4 revealed an eleven year old female admitted on [DATE] with a diagnosis of Bipolar, Post-traumatic stress disorder, Suicidal Ideation, anxiety, depression, and agitation. Review of the Nursing Flow Sheet/Progress Record dated 02/03/2013 revealed "Other Observations: BMP". Review of Nursing Flow Sheet/Progress Record dated 02/11/2013 revealed "Other Observations: BMP". Review of the Physician Orders revealed no order for a BMP. Review of the Master Treatment Plan dated 01/23/2013 revealed an active problem list Problem #1: Self Harm. Review of the MTP dated 01/23/2013 revealed Physician Intervention Strategy for Problem: Self Harm revealed no documentation of BMP. Continued review of the Master Treatment Plan Updates on 01/30/2013 and 02/06/2013 revealed no documentation of a BMP.

Interview on 03/14/2013 at 1045 with Nursing Administrative Staff revealed "there is no BMP order and nothing is documented on the treatment plan. I would expect to have a physician order and the BMP to be part of the treatment plan of care". Continued interview with Administrative Staff #1 on 03/15/2013 at 1220 revealed "the BMP absolutely should be a part of the master treatment plan and there should be evaluation of the effectiveness of the plan. There are discrepancies in the plan (BMP) interpretation. The process needs worked on".

Interview on 03/14/2013 at 1114 with RN#3 revealed "There is a BMP documented on the Nursing flow sheet/progress record on 02/03/2013 and 02/11/2013. This means the patient had a BMP in place. That means the patient should have an order by the physician. But there is no order for this patient (#4) to have a BMP and it is not listed on the treatment care plan. A BMP is developed by the treatment team...the physician writes the order for the BMP...we would expect her BMP to be on the Treatment Plan of Care."

Interview on 03/15/2013 at 1135 with RN #4 revealed "The documentation in the Nurses Notes indicates this patient (patient #4) had a BMP. But, I do not see a physician order on the chart for the BMP. It is discussed at treatment team and should be documented as part of the process. Then the physician writes an order for the BMP. There is no documentation of the plan progress and there is no update on the tretament plan. There needs to be a more formal process for incorporating the BMP in the treatment plan."





4. Open medical record review on 03/13/2013 of Patient #3 revealed a [AGE] year old female admitted IVC (involuntary commitment) on 02/13/2013 with the diagnoses of anxiety, depression, PTSD (Post Traumatic Stress Disorder), Bipolar disorder, agitation, SI (suicidal ideation), and HI (homicidal ideation). Review of the physician dictated "Admission Assessment Note" revealed patient #3 had a recent significant psychiatric hospitalization which resulted in discharge to a group home for further monitoring and therapy. Continued review of the patient's medical record revealed the patient had become agitated and labile at the group home where she resided and displayed "significant temper flare-ups." Review of the patient's medical record revealed presented with the chief complaint of "I want to hurt people."

Review of the current "Master Treatment Plan" (MTP) dated 02/13/2013 revealed no documentation of a BMP as part of the MTP.

Review of the patient's BMP (Behavior Modification Plan) dated 03/04/2013 per Physician #1 revealed "Patient (#3) is placed on BMP due to her special issues; she has a hard time with controlling her aggressive behavior she targets peers and impulsively attacks them without warning"...,and "Patient is allowed to take part in structured activities only and staff must be in room with her at all times."

Interview on 03/13/2013 at 1600 with Physician #1 revealed "BMP (Behavior Modification Plan) is ordered by the physician. I would expect the BMP to be on the care plan."

Interview on 03/13/2013 at 1640 with Nurse #1 revealed "the BMP should be documented on the Master Treatment Plan under behavioral problem."

Interview on 03/14/2013 at 1050 with Administrative Staff#1 revealed, "The BMP is physician driven during team conferences, then a physician order is written to implement the BMP." Continued interview revealed "the BMP is not included in the Treatment Plan on Patient #3's medical record."

5. Open medical record review of Patient #28 revealed a [AGE] year old male admitted IVC (involuntary committed) on 03/04/2013 with the diagnoses of Suicidal and Homicidal ideation toward his parents and oppositional defiant and bizarre behaviors. Further medical record review revealed Patient #28 was brought in by local police when he became aggressive and violent toward his parents and they feared for his and their safety.

Review of the current "Master Treatment Plan" dated 03/04/2013 revealed no documentation of a Behavior Modification Plan (BMP) as part of the MTP.

Review of the patient's BMP dated 03/12/2013 revealed Patient #28 was "placed on BMP due to his special issues; he has a hard time controlling his aggressive behavior; he targets his peers and impulsively attacks them without warning"..."Patient is allowed to take part in structured activities only and Staff Must Be In Room With Him At All Times."

Interview on 03/13/2013 at 1600 with Physician #1 revealed "BMP (Behavior Modification Plan) is ordered by the physician. I would expect the BMP to be on the care plan."

Interview on 03/13/2013 at 1640 with Nurse #1 revealed "the BMP should be documented on the Master Treatment Plan under behavioral problem."

Interview on 03/14/2013 at 1050 with Administrative Staff#1 revealed, "The BMP is physician driven during team conferences, then a physician order is written to implement the BMP." Continued interview revealed "the BMP is not included in the Treatment Plan on Patient #28's medical record."