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WAUKESHA COUNTY MENTAL HEALTH CTR 1501 AIRPORT RD WAUKESHA, WI Jan. 19, 2011
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on MR review, policy and procedure review, and staff interview, this facility failed to keep current the nursing care plan and comprehensive treatment plan for 1 out of 10 patients (Pt. #1) after a change in behavior occurred. Failure to update care plans with changes in behavior/condition has the potential to compromise the care and safety of all patients.

Findings include:

Facility policy titled, "Comprehensive Treatment Planning," dated 4/2009, was reviewed on 1/19/2011 at 2:05 p.m. by Surveyor # .
In section II., #7 states, "Assigned Treatment Team and Patient will review progress toward treatment goals weekly and modify plan as needed."

In an interview with DON B on 1/19/2011 at 8:15 a.m., B stated that the expectation is that when patients have a change in condition and or behavior, the care plan is updated."

A review of Pt. #1's closed MR was conducted on 1/18/2011 from 10:30 a.m.-12:00 p.m. and again from 6:15 p.m.-7:00 p.m. Pt. #1 is a [AGE] year old with Mood Disorder who was admitted to the facility on [DATE]. Pt. #1 has additional diagnoses of Developmental Delay, with a documented low intelligence quota and has several admissions to this facility, this being the 12th admission.

Pt. #1's nursing care plan, initiated on 12/2/2010, does not include inappropriate sexual behavior that occured on 12/15/2010.

Pt. #1's comprehensive treatment plan, which was formulated on 12/6/2010, initiated on 12/2/2010, does not include inappropriate sexual behavior that occured on 12/15/2010.

On 12/16/2010 there is an MD order from Dr. A to add inappropriate sexual behavior to Pt. #1's every 15 minute checks (Pt. #1 had been on every 15 minute checks for suicidal behavior and safety since admission on 12/2/2010).

This order is not reflected in the comprehensive treatment plan or in the nursing care plan except as a line item falling under the heading "Treatments," which, according to DON B on 1/19/2011 at 8:15 a.m., does not constitute a modification to the treatment plan/nursing care plan.

These findings were confirmed by DON B on 1/19/2011 at 8:15 a.m.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, MR review, staff interview, and review of facility incident reports, this facility failed to ensure that 2 out of 10 patients (Pt. #1 and 2) were safe from inappropriate sexual contact in their environment. Failure to maintain a safe environment has the potential to affect all in-patients admitted to this facility.

Findings include:

The facility's patient rights brochure titled, "Client Rights and the Grievance Procedure for Inpatient Services," dated 3/2009, was reviewed on 1/18/2011 at 12:25 p.m.
Under the section identified as "Personal Rights" the first bullet point states, "You must be treated with dignity and respect, free from any verbal, physical, emotional, sexual abuse or harassment."
The 7th bullet point states, "Your surroundings must be kept safe and clean."
The 9th bullet point states, "You have the right to receive treatment in a safe, psychologically and physically humane environment."

The facility's policy titled, "Observation Checks for Patient Safety and Whereabouts," dated July 15, 2008, was reviewed on 1/18/2011 at 12:15 p.m. In section I. #8. the policy states, "Patients on 15 or 30 minute checks must be directly observed."

According to PT G, in an interview conducted on 1/19/2011 at 1:00 p.m., the PTs are responsible for the observation checks and completing Patient Observation Monitoring forms for each day a patient remains on observation checks. These forms are not reviewed consistently by RNs and not signed off at the end of the RNs shift to confirm their accuracy.

The facility's policy titled, "Inappropriate Physical Contact Between Patients or Between Patients and Visitors," dated 6/2010, was reviewed on 1/19/2011 at 2:05 p.m. In section II. #1. the policy states, "Behavior such as physical aggression, or contact that is sexual in nature, whether the individuals consider the contact to be consensual or not consensual, is inappropriate."

A review of Pt. #1's closed MR was conducted on 1/18/2011 from 10:30 a.m.-12:00 p.m. and again from 6:15 p.m.-7:00 p.m. Pt. #1 is a [AGE] year old with Mood Disorder who was admitted to the facility on [DATE]. Pt. #1 has additional diagnoses of Developmental Delay, with a documented low intelligence quota and has several admissions to this facility, this being the 12th admission.

At the time of this admission (12/2/2010) Pt. #1 did not have a legal guardian and signed admission/treatment consent papers independently. Pt. #1 was ordered to have every 15 minute observation checks for suicidal behavior and patient safety from the time of the admission on 12/2/2010 through discharge on 12/30/2010.

A review of Pt. #2's closed MR for the time period of 12/13/2010-12/15/2010, and current open MR, was reviewed on 1/19/2011 at 9:55 a.m. Pt. #2 is a [AGE] year old with Schizoaffective Disorder. The admission of 12/13/2010 was Pt. #2's 6th admission to this facility.

At the time of the 12/13/2010 admission, Pt. #2 did not have a legal guardian and signed admission/treatment consent papers independently. Pt. #2 was ordered to have every 15 minute observation checks for suicidal and aggressive behavior and patient safety from the time of the admission on 12/13/2010 through discharge on 12/15/2010.

According to both MRs and the facility's incident reports, on the evening of 12/15/2010 at approximately 6:30 p.m., it was reported to Dr. D by a male patient on the unit that Pt. #1 and Pt. #2 were seen going into Pt. #1's hospital room together.

Dr. D promptly notified RN H who arrived at Pt. #1's room to find both patients disrobed and laying on Pt. #1's bed.

Pt. #1's "Patient Observation Monitoring Form," (behavioral observation form for every 15 minute checks) for the date of 12/15/2010 between the times of 6:15 p.m. and 6:45 p.m. indicate that Pt. #1 was participating in the day room area.

Pt. #2's Patient Observation Monitoring Form indicates Pt. #2 was participating in the day area from 6:15 p.m.-6:30 p.m. and there is no entry for the 6:45 p.m. observation.

In an interview with Dr. D on 1/19/2011 from 11:00 a.m. through 11:58 a.m., Dr. D confirmed the above incident and stated that the evening of 12/15/2010 the PT assigned to observation checks turned back to the desk to answer the phone and took eyes off the patient area. Dr. D also stated that neither patient, to D's recollection has any history of sexual inappropriateness.

Pt. #1 was immediately transferred off of the unit to another unit within the facility. Pt. #1 also was examined at an alternate facility after this incident where no signs of trauma were identified.

Pt. #2 was transferred to an alternate facility around 10:30 p.m. on 12/15/2010.

The incident and the findings were discussed and confirmed with DON B, Admin C, and Dr. D on 1/19/2011 at 3:00 p.m.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, MR review, and staff interview, this facility failed to provide an accurate record with legible entries in 1 out of 10 MR reviewed (Pt. #1). Failure to accurately document entries or properly correct them in the MR can lead to inconsistencies in the information recorded.

Findings include:

Facility policy titled, "Amending, Correcting, or Adding Information to a Medical Record," dated 12/12/08 was reviewed by Surveyor # on 1/19/2011 at 2:05 p.m. The policy outlines the procedure for correction of errors in documentation on page 2 of 3.
In Procedure I, item 1.1.1. states, "The author of the original entry shall draw a single line through the incorrect information without obliterating it."

A review of Pt. #1's closed MR was conducted on 1/18/2011 from 10:30 a.m.-12:00 p.m. and again from 6:15 p.m.-7:00 p.m. Pt. #1 is a [AGE] year old with Mood Disorder who was admitted to the facility on [DATE].

On 12/15/2010 RN I made an entry into Pt. #1's MR on a Staff Progress Note at 6:50 p.m. (entered as 1850 in military time).
The original documentation started as, "DD-at 1640 this nurse..." The time entered as 1640 (4:40 p.m.) was incorrectly documented and the actual time was to be 1840 (6:40 p.m.).

RN I corrected this error by writing over the time and making the "6" into an "8" thereby turning 1640 into 1840.

This method is not acceptable for correcting documentation errors and is not part of the facility's policy to do so.

In an interview with DON B on 1/19/2011 at 8:15 a.m., DON B stated that the error was detected during an internal audit of this MR and the nurse was directed to correct the error, however DON B was not aware that RN I corrected it by writing over the original entry.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on MR review and staff interview, this facility fails to document information regarding patient's past and current sexual activities in 10 of 10 MR reviewed (Pt.s #1-10). Failure to document this information could potentially expose vulnerable patients to unsafe situations.

Findings include:

This facility is a 28 bed acute psychiatric facility divided in to two units that are populated by male and female patients in the same area.

MR reviews were conducted on 1/18/2011 between 10:00 a.m. and 3:15 p.m. and on 1/19/2011 between 8:32 a.m. and 12:34 p.m. for Pt.'s #1 through 10. Pt.s #1-8 were closed records and Pt. 9 and 10 were open records.

There is no indication that a sexual history or current/recent sexual activity is recorded as part of the admission process.

These findings were confirmed on 1/19/2011 by DON B.

In an interview with Dr. D on 1/19/2011 from 11:00 a.m.-11:58 a.m., Dr. D confirmed that this information is not currently being obtained.