HospitalInspections.org

Based on observation, interview and record review, the hospital failed to monitor the safety of services and the quality of care for one of one patient (Patient #26) who was observed with an injury of unknown origin that was not reported through the hospital's quality assurance program until after identification by the surveyor. Hospital administration was notified of the injury 45 minutes after surveyor observation.

Finding included:

Patient #26 was observed on 06/30/15 with a round bruise on her left upper outer arm at 1214. The bruise was yellow discolored on the outer edges and the size of a small orange.

Personnel #24 was observed assisting Patient #26 with her lunch meal on 06/30/15 at 1216. Personnel #24 was asked about the bruise on Patient #26 and stated he was unaware of the bruise.

Personnel #24 stated on 06/30/15 around 1220 she did not know where Patient #26's bruise originated.

Personnel #30 stated on 06/30/15 around 12:25 at 12:22 that she had noticed the bruise on Patient #26 earlier that morning but did not notify anyone.

Personnel #43 stated on 06/30/15 at 16:25 she had assisted Patient #26 with her shower the day before, on 06/29/15. Personnel #43 stated she had noticed the bruise on Patient #26's arm at that time but "thought it [the bruise] was from the hospital." Personnel #43 denied that she reported the bruise to nursing or administration.

Personnel #4 was interviewed on 06/30/15 at 13:45 and stated she was unaware of Patient #26's bruise until staff had pointed it out to her "a few minutes ago and...[Personnel #41] will make out an incident report."

Personnel #2 stated on 07/02/15 at 10:25 that administration was notified of Patient #26's injury of unknown origin after the surveyor identification.

A hospital provided incident report about Patient #26's injury of unknown origin was dated 06/30/15 at 13:00.

Physician Orders dated 06/11/15 at 10;40 reflected Patient #26's admission to the Inpatient Geropsychiatric Program. Admission diagnoses included Bipolar Disorder, Dementia, Asthma, and Hypertension. Admission medication orders did not reflect blood thinning medications.

Record review of the skin assessment dated 06/11/15 did not document a bruise on Patient #26's outer upper arm.

Multidisciplinary Progress Notes dated 06/30/15 at 10:00 did not reflect a bruise on Patient #26.

Based on interviews and record review the hospital failed to ensure the Director of Nursing provided adequate supervision to ensure that staff removed items that could be used for patient self-injury and preventing staff from inappropriate destruction of a part of a medical record. 1 of 1 patient (Patient #7's) original nursing documentation was removed and re-written per the instruction of Personnel #7 on 06/17/15 when Patient #7 ingested a foreign body.

Findings included:

Patient #7's High Risk Notification Alert dated 06/16/15 timed at 1445 reflected, "Suicidal/Self Harm...hang, ingestion of objects...involuntary."

The Child/Adolescent Admission Medication Orders dated 06/16/15 timed at 0530 reflected, "(close observation) 15 minute checks...precautions, elopement and assault precautions..."

The Physician Daily Progress Note dated 06/17/15 timed at 0936 reflected, "Risk to self and others...suicidal intent...plan...hanging..."

The 06/17/15 multidisciplinary progress note dated 06/17/15 timed at 1815 reflected, "Patient eating dinner at 1700...began throwing up clear chunks of fruit...requested Maalox...for GI (gastrointestinal) upset at 1730...calm in large lounge...at 1800 patient began throwing up again...complained of stomach pain...reported it feels scratchy...stated I swallowed a piece of metal...history of swallowing objects...Dr. notified...order to go...ER (emergency room)." No documentation was found as to what type of metal object was ingested and the details surrounding where the object was located.

On 06/30/15 at 1041 Personnel #36 was interviewed by telephone. Personnel #36 stated the technician reported Patient #7 was throwing up. Personnel #36 stated she gave the patient some Maalox and then a short time later the patient began throwing up again. Personnel #36 stated the patient told her he had swallowed a piece of metal. Personnel #36 stated she inquired as to where he obtained the metal. Personnel #36 said the patient informed her he ingested a piece of metal off the lid to a dominos box. Personnel #36 stated she asked the patient where the dominos box was located. The patient pointed to a corner of the dayroom behind a column. Personnel #36 said the dominos box was retrieved and she observed a large piece of metal missing from the lid of the box. Personnel #36 stated she sent the lid off the dominos box with emergency personnel to Hospital C with Patient #7. Personnel #36 stated she documented all the details of the event which included information regarding the dominos box.

Personnel #36 stated she clocked out and went home. Personnel #36 stated she was contacted by Personnel #7 approximately one hour later and instructed to return to work and re-write her note. Personnel #36 stated Personnel #7 informed her to use her original note and exclude the information regarding the dominos box. Personnel #36 stated Personnel #7 informed her that removal of the original note was not removing it from medical record as the note was not in the chart yet as it was still on the clipboard. Personnel #36 stated she did as she was instructed even though she felt uncomfortable.

On 06/30/15 at 1202 Personnel #7 was interviewed by telephone. Personnel #7 was asked if she telephoned Personnel #36 to return to work. Personnel #7 stated she did. The surveyor asked Personnel #7 the reason Personnel #36 was asked to return to work. Personnel #7 stated she asked Personnel #36 to return and change her note. Personnel #7 was asked why by the surveyor. Personnel #7 stated "because of the recent safety issues identified by the State." Personnel #7 said she was not thinking at the time she did not feel like this was falsification of a medical record. Personnel #7 was asked if she spoke with anyone about the event. Personnel #7 stated she spoke with Personnel #2 regarding the note being changed. Personnel #7 stated she asked Personnel #2 if they could get the original note out of the shred box. Personnel #7 stated Personnel #2 did not say anything.

On 06/30/15 at 1600 Personnel #19 was interviewed by telephone. Personnel #19 stated when he arrived on duty the patients were playing with the dominos and the metal box/tin was in the dayroom. Personnel #19 stated the dominos are generally kept in the nursing station. Personnel #19 verified a piece of metal had been removed from the lid of the metal box. Personnel #19 was asked if he was aware Patient #7 had a history of ingesting foreign bodies. Personnel #19 stated he was unaware the patient ingested foreign bodies.

On 06/30/15 at 1315 Personnel #37 was interviewed by telephone. Personnel #37 stated she was present when Personnel #36 was instructed by Personnel #7 to return to work and to re-write her note excluding the information regarding the dominos box. Personnel #37 stated sometime later in the shift Personnel #3 telephoned her and wanted to know if Personnel #36 returned to work to change her note. Personnel #37 stated she informed Personnel #3 that Personnel #36 returned and changed her note. Personnel #37 stated the entire event put herself and the other nurse in a bad position.

The policy entitled, "Employee Conduct and Work Rules" with a creation date of 02/2004 reflected, "To provide guidelines for personal conduct...falsifying records, including false or misleading information on...work reports, official documents, patient records..."

Based on record review and interview, the facility failed to identify the full name of staff persons responsible for ensuring that specific interventions selected for five (5) of eight (8) active same patients (A2, B1, C1, E4 and F6) were consistently listed on the Master Treatment Plans (MTPs). The responsible staff column on the plans primarily contained the first or last name, initials only, or an illegible signature for many of the interventions. This practice results in the facility's inability to clearly monitor staff accountability for seeing that a specific intervention is carried out.

Findings include:

A. Record Review

1. Facility policy number TMNS.NURS.101, titled "Treatment Planning", last revised 6/2015, had the following instructions for responsible staff on Master Treatment plans - "Staff initiating intervention, write in staff name that initiated the intervention."

2. Active sample patient A2, MTP dated 6/20/15
For the problem of "Out of contact with reality",
The nursing interventions were: "RN Assessment to determine mood, and patient perception of effectiveness of medications, 1:1 patient education regarding effects, benefits and give effects of Risperdal, goals and warp-up group to assist patient in setting productive goals." All three interventions had initials for responsible nursing staff.
The activity therapy intervention was "Activity therapy group to provide patient skills in reality." The responsible person was an initial.

3. Active sample patient B1, MTP dated 6/23/15
For the problem of "out of contact with reality",
The RN (registered nurse) intervention was "RN Assessment to determine mood, and patient's perception of effectiveness of medications." The responsible person listed contained only the first name of the person.

For the intervention "goals and wrap-up group to assist patient in setting productive goals",
The mental health technician's initials only were down as the responsible person.
For the social worker's interventions of "psychcoeducation groups on coping & [and] communication skills to develop self-care skills, process group to provide patient OPB [opportunity] express self [sic], patient education regarding illness to promote self-care and prevent relapse, only the responsible social worker's initials were present for all three interventions."
The same intervention deficiencies for the problem of "potential for self-harm" were the same as above for the disciplines mentioned above -nursing, social workers and activity therapists.

4. Active sample patient C1, MTP dated 6/25/15
For the problem of "potential for self-harm",
The nursing interventions were: "RN Assessment to determine suicidality, mood, and patient perception of effectiveness of medications; 1:1 patient education regarding effects, benefits and side effects of Celexa"; and "goals and wrap-up group to assist patient in setting productive goals." The responsible person had initials only for nursing staff.
The social work interventions were: "psych education groups and self-harm, coping skills, stress management, process groups to provide opportunity to express thoughts and feelings." The responsible social worker had initials only.
The activity therapy intervention was "activity therapy groups to provide patient skills in coping skills." The responsible person listed was "CTRS" [Certified Therapeutic Recreation Specialist].

5. Active sample patient E4, MTP dated 6/19/15
For the problem of "out of control with reality",
The nursing intervention was "RN Assessment to determine mood, and patient perception of effectiveness of medication." The responsible nurse was initials only.
For the social work intervention of "psych education groups on memory, processing, safety & [and] trust, getting needs met to develop self-care skills", the social work signature was illegible.

6. Active sample patient E6, MTP dated 6/26/15
For the problem of "out of control with reality",
The nursing interventions were: "RN Assessment to determine mood, and patient perception of effectiveness of medications; 1:1 patient education regarding effects, benefits and side effects of medications". The first name only of the responsible nurse was listed for both interventions,

For the social work intervention of "individual/family therapy involving all in D/C [discharge] planning", the first name only of the social worker was listed as the responsible person.


B. Interviews

1. On 6/30/15 at 9:10 a.m., the facility's Risk Manager and the Corporate Divisional Clinical Director were shown the Master Treatment plans of patient C1, dated 6/25/15. The "responsible staff for the interventions by nursing was identified solely as DL". Both staff stated the use of initials were not clear as to who this individual is and they agreed that the signature of the nurse member of the treatment team was not the one with the initials next to the nursing interventions

2. In an interview on 6/30/15 at 11:000 a.m., the failure to include full names of disciplines responsible for implementing interventions on the MTP was discussed with the Director of Nursing. She stated that initials and first or last names only were not acceptable. "Both names of responsible disciplines should be present."