HospitalInspections.org

Based on clinical record review, review of facility policies and staff interview, for one (1) of one (1) patient reviewed, Patient #100, who utilized ambulatory restraints for transportation to and from ECT treatments at Facility #2, the facility failed to ensure the least restrictive intervention was utilized. The findings include:

Patient #100 with multiple mental health diagnoses was admitted to the facility on April 5, 2005 following decompensation of schizoaffective disorder, bipolar type. On 11/25/09, a consult was conducted to evaluate the patient based on his/her deterioration after the discontinuation of clozapine treatment in September 2009 as a result of develping a reaction to the clozapine. The evaluation identified Patient #100 as becoming increasingly disorganized, paranoid and delusional, requiring placement on a 2:1 staff to patient ratio due to aggressive, violent behaviors, attempts to harm himself/herself and staff and attempting to strike out at staff on a daily basis, and that an ECT may be used to target the patients aggression, suicidality and homicidality as well as mood lability. The recommendations included ECT treatment three (3) times a week at Facility #2, that the patient be transported by ambulance and accompanied by three (3) staff members and in full restraints to be removed only during the patients treatment. A court order was obtained on 12/23/09 for consent for the ECT treatments for Patient #100. Review of the Restraint and Authorization Forms from 12/28/09 when the ECT treatments were initiated through 2/1/10, identified that three (3) of the thirteen (13) forms reviewed, e.g. 1/11/10, 1/13/10 and 1/18/10 identified ambulatory restraints were necessary to prevent the patient from harming self and/or others; the less restrictive interventions utilized identified "Other- for medical treatment"; the rationale for the type of restraint identified restraints were for the protection of others and/or self; and the restraint utilized identified "Ambulatory wristlets" e.g. ambulatory restraints. Documentation under the MD assessment for 1/13/10 and 1/18/10 identified, in part, that the restraints were necessary to prevent the patient from harming themselve or others. Documentation for 1/11/10 identified, in part, that the patient was still impulsive, angry and making delusional statements. Review of the RN's Assessment and Progress notes identified that the patient willingly allowed the restraint to be applied on all three dates identified. Documentation, in part, further identified on 1/11/10 that the patient was calm, co-operative, with verbal and delusional statments., on 1/13/10 co-operative, confused and delusional and on 1/18/10 the patient was identified as delusional, talkative and slightly agitated. Review of Physicians Orders identified ambulatory restraints on 1/11, 1/13, and 1/18/10 for ECT treatments.
Review of the facility policy entitled Patient Rights identified, in part, that restraint may only be used when the patient presents an imminent serious risk of injury to himself or others and all less restrictive interventions have failed. Review of the policy entitled Restraint Use to Prevent Harm identified that restraints would be utilized only as an emergency measure after all other less restrictive measures have been attempted and failed.
MD#1 during interview on 2/3/10 regarding assessing for the least restrictive restraint for Patient #100 during transportation to the ECT treatments verbalized concern for the safety of the patient and staff in the back of the ambulance as this patient continues to exhibit ongoing behaviors. RN#1 identified in interview that Patient #100 utilizes a 2:1 staff to patient ratio (6:00 AM-midnight) and a 1:1 staff to patient ratio (midnight to 6:00 AM). RN#1 on 2/3/10 further identified that the patient should be evaluated for the least restrictive restraint. Documentation failed to identify the patient was assessed for the least restrictive restraint.

Based on clinical record review, staff interviews and review of facility documentation for one patient (Patient #50), the facility failed to ensure that the patient's Interdisciplinary Recovery Plan was revised in accordance with facility policy.

The findings include:

Patient #50 was admitted to the facility on 5/8/07 for treatment related to mood disorder and substance abuse. The patient's Master Recovery Plan of 5/8/09 identified goals that included developing two life skills to prepare the patient for community living. Interventions included providing the patient with cooking group and personal management group weekly. Master Recovery Plan reviews from June, 2009 through January, 2010 identified that the patient consistently failed to attend personal management and/or cooking groups and made no progress in the area of life skills. Review of the Master Recovery Plan Reviews for the period of June, 2009 through January, 2010 failed to reflect that new or revised interventions were identified as a result of the patient's lack of progress. Upon interview on 2/2/10 at 3:00 pm, the Director of Rehabilitation services stated that the patient's motivation and insight was affected with the recent loss of a family member, and although not reflected in the Master Recovery Plan reviews, the patient was working with a Mental Health Associate to develop social skills such as shopping, leisure activities, etc. Review of the facility's Recovery Planning Policy indicated that the interdisciplinary Recovery Plan Review is an evaluation of the patient's progress towards identified goals and effectiveness of prescribed treatement interventions. Goals and interventions are to be revised as appropriate.

1. Based on a tour of the hospital and staff interview, the facility failed to ensure that the psychiatric unit was maintained in such a manner as to promote the safety and well being of patients.

a. On 02/03/10 and 02/04/10 at 09:00 AM and various times throughout the day, while touring the adult psychiatric units on West 3, 2, 1 and East 3, 2, 1 and ancillary support spaces in the basement/ground floor with the Director of Plant Operations, the following was observed:
The faucet and shower controls, flushometers, door handles, door hinges, door closers and privacy curtains in shower areas and patient rooms posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard. Subsequent interview of the Director of Plant Operations and the Facility Plant Engineer II on 02/04/10 indicated that they were working on a completed risk based analysis prior to this inspection and no date for completion for West 3, 2, 1 and East 3, 2, 1 had been identified.

b. On 02/03/10 at 10:00 AM and various times throughout the day, while touring the Blue Hills Facility (Off Site) @ Capital Region Complex with the Facility Plant Engineer II (PFE II) the following was observed:
The faucet and shower controls, flushometers, door handles, door hinges, posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard. Subsequent interview of the Director of Plant Operations and the Facility Plant Engineer II on 02/04/10 indicated that they were working on a completed risk based analysis prior to this inspection and no date for completion had been identified.

Based on clinical record review, staff interviews and review of facility documentation, the facility failed to ensure the effectiveness of the infection control program's plan for influenza vaccination of patients.

The findings include:

Patient #40 was admitted to the facility on 12/9/09 as a voluntary admission. Physician orders dated 12/15/09 and 12/23/09 directed the administration of the seasonal flu and H1N2 (swine) flu vaccination respectively. Review of the patient's Medication Administration Record (MAR) through 2/2/10 failed to refect that the vaccinations had been administered although an unsigned flu vaccine consent was filed in the clinical record. Review of the facility's infection control Program minutes of 12/15/09 identified that flu vaccines would be made available to all patients/staff and that consents would continue to be sent for conserved patients. The 2009-10 second quarter infection control report identified that the threshold for vaccines administered would be 95 percent. Review of facility documentation outlining flu vaccine administration for all patients as of 2/2/10 reflected that for a combined campus census of 116 patients on 2/2/10, 52 had received the seasonal flu vaccine and 30 had received the H1N1 vaccine. Upon interview on 2/3/10, the Director of Medical Services stated that patients at the facility are generally long term and that the facility policy is for all patients to recieve the flu vaccine. Upon interview on 2/2/10, the Infection Control Practitioner stated that the goal is for 100 percent patient vaccination beginning in October, 2009 and as consents are signed and become available, the vaccine is given. For patients ahle to give consent, unit nurses should be administering the vaccine. Review of infection control minutes failed to reflect that the effectiveness of the influenza vaccine program had been evaluated and/or practices implemented to improve the administration rate for patients.