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.

WILLOW CREEK BEHAVIORAL HEALTH 1351 ONTARIO RD GREEN BAY, WI 54311 Dec. 20, 2017
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, staff at this facility failed to develop and/or update patient treatment plans related to falls in 3 out of 9 patients identified to be at risk for falls (Patient #4, 7, and 9), and failed to develop a goal for wound management in 1 of 1 patients identified to have an open draining wound on admission (Patient #5).

Findings include:

The facility's policy titled, "Fall Risk Precautions," #1000.51, dated 10/01/2016, was reviewed on 12/18/2017 at 12:59 PM. The policy does not indicate that patient's at risk for falls should have a falls problem, goals, and interventions added to their treatment plan. Per interview with Director of Nursing A on 12/18/2017 2:54 PM regarding treatment plans and falls, Director A stated that patients identified to have a moderate to high risk for falls should have a problem opened up in their treatment plan for them.

The facility's policy titled, "Treatment Plan Acute Inpatient," #1200.9, dated 10/1/2016, was reviewed on 12/19/ 2017 at 3:00 PM. The policy revealed in part, "Each patient admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments...The treatment planning process is continuous, beginning at the time of admission and continuing through discharge."


Falls:
Patient #9's closed medical record was reviewed on 12/18/2017 at 3:23 PM accompanied by Director of Nursing A who confirmed the following findings at the time of the record review: Patient #9 was admitted on [DATE] and assessed to have a high risk for falls score of 26 on admission. There is no falls problem, goal or interventions identified in Patient #9's treatment plan. Per interview with Director A on 12/18/2017 at 3:23 PM, Director A stated, "No, there is no falls problem identified."

Patient #4's closed medical record was reviewed on 12/19/2017 at 8:02 AM accompanied by Director of Nursing A who confirmed the following findings at the time of the record review: Patient #4 was admitted on [DATE] and was assessed to have a high risk for falls score of 24 on admission. A falls problem, goals and interventions were identified on the treatment plan on 11/14/2017 and was updated on 11/15/2017 at 5:00 PM. Patient #4 had a fall on 11/15/2017 at 6:10 PM, 11/23/2017 at 12:30 PM and 11/23/2017 at 6:55 PM. There were no updates to the treatment plan after any of these falls to attempt to improve patient safety. Per interview with Director A on 12/19/2017 at 8:45 AM regarding Patient #4's interventions for falls, Director A stated, "We were continuing to use the interventions we have available to us." Director A stated that 1:1 observation status is primarily reserved for behavioral concerns, and not used for falls.

Patient #7's closed medical record was reviewed on 12/19/2017 at 10:12 AM accompanied by Director of Nursing A who confirmed the following findings at the time of the record review: Patient #7 was admitted on [DATE] and assessed to have a falls risk score of 13 (low side of high risk). Patient #7's treatment plan has a falls problem identified with a start date of 11/7/2017, however there were no goals or intervention. Patient #7 had a fall on 11/14/2017 and the care plan was unchanged. Per interview with Director A on 12/19/2017 at 10:20 AM, Director A stated, "I was looking through the care plan last night and there were goals and interventions there, but now there are not." Review of the incident report filed on 11/14/2017 after Patient #7's fall, the previous risk manager identified that there was no falls treatment plan in place.

Wound:
Patient #5's closed medical record was reviewed on 12/19/2017 at 9:08 AM accompanied by Director of Nursing A who confirmed the following findings at the time of the record review: Patient #5 was admitted on [DATE], and the nursing skin assessment on admission revealed that Patient #5 had a small skin tear on the anterior left leg that was leaking clear fluid. Patient #5 also had non-pitting edema and cellulitis (tissue inflammation) to both lower extremities. There are no goals or interventions related to Patient #5's draining wound on the treatment plan.