HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:
1) Failure to ensure there was adequate staff to effectively manage physically aggressive patients (See Findings Tag A0144);
2) Failure to ensure patients did not have access to the nurse's station and unsecured areas of the building (See Findings Tag A0144);
3) Failure to ensure the patient care area was free of ligature risks (See Findings Tag A0144);
4) Failure to ensure the nurse call system was functioning in 9 (a - j) of 9 (a - j) patient bedrooms and Room "o" (See Findings Tag A0144); and
5) Failure to ensure patients were being monitored per provider order (See Findings Tag A0144).

Based on observation, record review and interview, the hospital failed to ensure the patient received care in a safe setting. The deficient practice was evidenced by:
1) Failure to ensure there was adequate staff to effectively manage physically aggressive patients;
2) Failure to ensure patients did not have access to the nurses' station and unsecured areas of the building;
3) Failure to ensure the patient care area was free of ligature risks;
4) Failure to ensure the nurse call system was functioning in 9 (a - j) of 9 (a - j) patient bedrooms and Room "o"; and
5) Failure to ensure patients were being monitored per provider order.
Findings:

1) Failure to ensure there was adequate staff to effectively manage physically aggressive patients

The facility was unable to produce a policy related to a timeframe of when a "Stat" or as soon as possible medication order for an as needed medication should be administered or a policy related to a timeframe of medication administration to assist with patient de-escalation. The facility was also unable to produce a policy related to the procedure to follow when a patient is unable to be physically controlled.

A review of hospital policy, "PC-1012: Police/Law Enforcement Assistance & Patients in Custody of Law Enforcement," with an effective date of 07/10/2012 and no revisions, revealed in part: "Policy: Law enforcement officials will be provided with the opportunity to place his/her weapons in a lock box in an effort to maintain a weapon's free environment. Procedure: Use of Assistance from Law Enforcement: 1. Upon arrival at the facility, law enforcement officials will be advised of the hospital's no weapons policy. 2. Law enforcement officials will have the option to place his/her weapons in a provided lock box or retain as part of his/her uniform while on the unit. a. If the law enforcement official chooses to relinquish his or her weapon, the weapon will be placed in the lock box and the officer will retain the key to box while on the unit. b. Law Enforcement Officials electing to exercise the right to retain their weapon on part of their uniform: i. Acknowledge that they understand the hospital maintains a weapons free environment and they choose to retain their uniform weapon despite the hospitals "No Weapon Policy." ii. Assert that they have been trained in the use and care of their weapon(s) and they choose not to relinquish their uniform weapons while on the psychiatric unit. Instead, they may enter the unit in full uniform (uniform weapons included) in order to assist staff in keeping a patient from causing harm to him/herself or others. iii. The law enforcement department which employs law enforcement officials takes full responsibility for training law enforcement officials in the proper use and care of weapons on a psychiatric unit. 3. In the event law enforcement officials make the decision to use their uniform weapons to ensure safety, staff will not assist law enforcement officials with the use of the weapons. At the time weapon use is required law enforcement will notify staff to leave the area. Staff will step out of room and will re-enter as soon as law enforcement notifies staff it is safe to return to the area."

Observations of recorded video from 11/21/2024 6:51 PM to 7:25 PM revealed Patient #1 standing at the nurses' station and looking into the window. Patient #1 remains at the window looking through the glass until Sheriff Officer (SO) 1 enters the unit from the nurses' station door at 6:57:36 PM. SO1 appears to speak with Patient #1 as 4 MHT's and 1 LPN also approach and surround the patient. At 6:59:57 PM, SO2 enters the unit from the nurses' station door and begins to speak with the patient. Hospital staff remain within 5-8 feet of the patient. At 7:02:17 PM, SO2 appears to reach for Patient #1 and an ensuing altercation begins. Over the next several minutes the video revealed the interaction of the 2 sheriff officers and hospital staff attempting to hold the patient on the floor as S3LPN administered an injection. After the injection was administered, and while Patient #1 continued to be held on the floor, Patient #1 was able to grab hold of SO1's weapon while it appeared to remain holstered and pull the trigger. SO1 was struck in the leg by the bullet. The hospital staff immediately ran away from the altercation and left the 2 officers attempting to gain control of Patient #1. SO2 was able to pull the patient's arms and hands away from SO1's weapon and restrain Patient #1 in a position that allowed SO2 to retrieve his weapon, place it against Patient #1's left upper chest and fire his weapon. Patient #1 continues to resist the officers for another 60 seconds until SO2 was able to completely maneuver Patient #1's hands away from SO1, position Patient #1 face down with his hands behind his back and place handcuffs on the patient.

In an interview on 11/26/2024 at 11:20 AM, S3LPN confirmed she was the medication nurse on duty on the night of the above mention incident. She described the situation as she arrived at work on 11/21/2024 at approximately 5:50 PM, Patient #1 was pacing the unit, walking in and out of his assigned room, staring in the nurses station and saying inappropriate things to the staff. She received report of an injection being ordered by S10APRN at 2:15 PM for escalating behaviors, however it was reported the injection had not been administered due to the daytime staff not feeling as if they had an adequate amount of staff to assist with holding the patient to administer the injection. The combined day and night shift staff decided to attempt to administer the injection together. Patient #1 was escorted to his assigned room and the staff attempted to approach Patient #1 and he begin to physically push staff away and assault them. S3LPN indicated Patient #1 pushed her against the wall with his back and begin elbowing her in the chest and head. As he was elbowing S3LPN, Patient #1 also had hold of S9MHT's hair and was pulling her around by her hair. S3LPN indicated she was eventually able to free herself and S9MHT was able to escape the patient's hand grip after he pushed her on to the bed. After all staff were able to exit the room, they retreated to the nurses station. SLPN indicated at this point, she made the decision to contact the Sheriff's Office. S33LPN called the Sheriff's Office at 6:10 PM. S3LPN indicated S1CEO was contacted and updated, S1CEO instructed the staff to use their de-escalation training to gain control of the patient and administer the injection. S3LPN indicated the staff did not feel comfortable with attempting to gain control of the patient after they had been physically assaulted. At 6:37 PM, S3LPN indicated she made a second attempt to contact law enforcement for assistance and this assistance arrived around 7:00 PM. S3LPN further confirmed upon the Sheriff Officers arrival to the hospital, she made a request to the officers to lock their weapons up and not bring the weapons on the unit, however she indicated the request was not answered or acknowledged.

In an interview on 11/27/2024 at 8:15 AM, S1CEO confirmed he was contacted on 11/21/2024 at approximately 6:10 PM regarding Patient #1's escalating behaviors. He further confirmed he was aware of the patient's behaviors throughout the day, but he was unaware the medication ordered at 2:15 PM had not been administered. S1CEO confirmed the current staff on duty was not able to effectively manage or physically control Patient #1 and law enforcement was contacted to assist with the physical hold of Patient #1 for medication injection. S1CEO confirmed the hospital had contacted law enforcement in the past to assist with a physical hold of a patient, but S1CEO was unable to provide a date(s) or the actual number of occurrences law enforcement has been contacted for assistance in holding a patient to receive an injection. S1CEO confirmed it is the responsibility of the hospital to provide the necessary staff to effectively control, monitor and/or physically hold their patients. S1CEO confirmed the facility had enough staff on duty according to staffing policy, however it was not enough staff to effectively control, monitor and/or physically hold Patient #1.

The nursing staff on the day shift of 11/21/2024 were not available for interview.

2) Failure to ensure patients did not have access to the nurses' station and unsecured areas of the building

Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed Rooms "c," "f," "j," "k," and "m" entry doors were unlocked and unsecured which could allow patients to access these rooms without being monitored and/or observed for safety.

In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings and further confirmed the doors should be locked.

Observations of video recorded on 11/21/2024 from 11:20 AM to 11:35 AM revealed the camera view of the interior of the nurses' station. Patient #3 was standing outside the nurses' station and appeared to be asking S5LPN a question. The S5LPN retrieves a medical record and allowed the patient to observe a document in the medical record. Then S5LPN opens the door to the nurses station to allow the patient to observe the document and remains in the open doorway while the patient observes the medical record. At 11:24:25 AM, S5LPN and Patient #3 appeared to be conversing as the patient attempts to lunge towards the nurse and enter the nurses' station. S5LPN was able to prevent the patient from entering and the patient retreats back slightly. S6RN was working at a nearby desk in the nurses station and begins to assist by helping to block the doorway as the conversation continues. S4MHT entered the nurses station and stood behind the 2 nurses. Approximately 6 minutes elapsed with the nurses' station door in the open position, S5LPN and S6RN standing in the doorway and the patient approximately 1-2 feet in front of them. During this time frame, the video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurses station doorway. At 11:30:01 AM, Patient #3 is observed pushing her way through S5LPN and S6RN. S4MHT attempted to assist however Patient #3 overpowers all 3 staff and made her way to the exit door of the nurses' station leading the main entrance of the building. Another camera recorded Patient #3 exiting the building at 11:30:18 AM with S4MHT in pursuit. During the before mentioned time frame of the video reviewed, there were no other observable staff seen on video.

In an interview on 11/24/2028 at 4:00 PM, S1CEO and S2DON confirmed the recorded video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurse's station doorway. Further they confirmed the staff have been instructed to not allow the nurses station door to remain open.

3) Failure to ensure the patient care area was free of ligature risks

Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed loosely secured toilet seats in the restrooms of 9 (a - j) of 9 (a - j) patient bedrooms. This style toilet seat, even when properly secured, created a ligature risk where as an item such as a bed sheet could be passed between the toilet bowl and the toilet seat and used for potential injurious behaviors.

Further observations revealed sleigh bed style bed frames (plastic head board and foot board touch the floor and are connected via an above floor plastic platform for mattress placement) in 4 (b, c, e, g) of 9 (a - j) patient bedrooms. This style frame creates multiple ligature risk points that an item such as a bed sheet could be wrap around and used for potential injurious behaviors.

In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO and S2DON confirmed the above mentioned findings.

4) Failure to ensure the nurse call system was functioning in 9 (a - j) of 9 (a - j) patient bedrooms and Room "o"

Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed the nurse call system not alerting the nurses station when activated in 9 (a - j) of 9 (a - j) patient bedrooms and Room "o."

In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO and S2DON confirmed the above mentioned findings.

5) Failure to ensure patients were being monitored per provider order

A review of hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and last revised 07/31/2012 revealed in part: "Policy: All patients are monitored as to their location and activity at regular intervals. Procedures: A) Routine Levels of Observation: 1) All patients are monitored a minimum of once every 15 minutes. B) Special Levels of Observation are as follows: 1) Constant Observation: a. a patient is maintained in community areas where they can be observed at all times when the patient'sconditionrequires a more intense levelof observation and contact. b. Patients on a constant observation status must be accompanied if leaving the community area, e.g. to bathroom or to change clothes. c. Documentation of constant observation will be completed on observation sheets."

A review of hospital policy, "PC-1014: Patient Observation Record (15 Minute Check Sheet)," with an effective date of 07/10/2012 and last reviewed 12/27/2021 revealed in part: "Purpose: a designated MHT or other assigned staff will note and document patients' location and behavior every fifteen minutes on the Patient Observation Record."

Observations of video recorded on 11/21/2024 from 11:20 AM to 11:35 AM revealed the camera view of the interior of the nurses' station. Patient #3 was standing outside the nurses' station and appeared to be asking S5LPN a question. The S5LPN retrieves a medical record and allowed the patient to observe a document in the medical record. Then S5LPN opens the door to the nurses' station to allow the patient to observe the document and remains in the open doorway while the patient observes the medical record. At 11:24:25 AM, S5LPN and Patient #3 appeared to be conversing as the patient attempts to lunge towards the nurse and enter the nurses' station. S5LPN was able to prevent the patient from entering and the patient retreats back slightly. S6RN was working at a nearby desk in the nurses' station and begins to assist by helping to block the doorway as the conversation continues. S4MHT entered the nurses' station and stood behind the 2 nurses. Approximately 6 minutes elapsed with the nurses station door in the open position, S5LPN and S6RN standing in the doorway and the patient approximately 1-2 feet in front of them. During this time frame, the video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurses' station doorway. At 11:30:01 AM, Patient #3 is observed pushing her way through S5LPN and S6RN. S4MHT attempted to assist however Patient #3 overpowers all 3 staff and made her way to the exit door of the nurses' station leading the main entrance of the building. Another camera recorded Patient #3 exiting the building at 11:30:18 AM with S4MHT in pursuit. During the before mentioned time frame of the video reviewed, there were no other observable staff seen on video.

A review of the hospital records revealed the following staff scheduled at the time of the elopement: S4MHT, S5LPN, S6RN, S7MHT, and S8MHT.

A review of the hospital census at the time of the above mentioned elopement revealed 10 patients with the current level of observations: 2 patients on line of sight (LOS) and 8 patients on every 15 minutes.

A review of Patients #1 - #10 medical record revealed:
Patient #1: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT;
Patient #2: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT;
Patient #3: Patient eloped;
Patient #4: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT;
Patient #5: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT;
Patient #6: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT;
Patient #7: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT;
Patient #8: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT;
Patient #9: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; and
Patient #10: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT.

The above mentioned observations of recorded video included the timeframe of the above mentioned observation checks on 11/21/2024 at 11:30 AM. S4MHT was observed on video being involved with Patient #3 prior to an elopement and leaving the building in pursuit of Patient #3 at 11:30 AM. The Patient Observation Logs revealed S4MHT initials indicating an observation on 3 (#1, #6, #8) of 10 (#1 - #10) patients at 11:30 AM. This surveyor did not observe any recorded video of S8MHT or S9MHT on the unit during the above mentioned time frame. The Patient Observation Logs revealed S7MHT initials indicating an observation on 3 (#4, #5, #9) of 10 (#1 - #10) patients at 11:30 AM and Patient #4 was a LOS. The Patient Observation Logs revealed S8MHT initials indicating an observation on 3 (#2, #7, #10) of 10 (#1 - #10) patients at 11:30 AM and Patient #2 was a LOS.

In an interview on 11/27/2024 at 10:35 AM, S1CEO confirmed the above mentioned observations checks were not performed. S1CEO indicated video review by himself, confirmed S7MHT and S8MHT had left the building at 11:09 AM. S1CEO further confirmed the other 9 patients were not being monitored per physician orders.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by:
1) Failure to document a nursing shift assessment on 2 (#2, #3) of 3 (#1 - #3) patient's medical record reviewed;
2) Failure to accurately document observation check performance by the mental health techs (MHTs) on 9 (#1, #2, #4 - #10) of 10 (#1 - #10) patients.
Findings:

1) Failure to document a nursing shift assessment on 2 (#1, #2) of 3 (#1 - #3) patient's medical record reviewed

A review of hospital policy, "PC-62: Charting-Nursing," with an effective date of 07/10/2012 and no revisions, revealed in part: "Policy: It is the policy of the nursing department to regularly and accurately record pertinent information on all patients. Procedure: 1) The nurse's documentation should include the following: a) a chart entry shall be made every shift on every patient."

A medical record review revealed the following:
Patient #1: An admission on 11/19/2024 at 3:30 AM and a discharge on 11/21/2024 at 7:32 PM. A review of nursing shift assessments revealed no documentation of a shift assessment being performed on the day shifts of 11/20/2024 and 11/21/2024.

Patient #2: An admission on 11/16/2024 at 4:15 AM and a discharge on 11/22/2024 at 12:30 PM. A review of nursing shift assessments revealed no documentation of a shift assessment being performed on the day shifts of 11/16/2024, 11/17/2024, 11/20/2024 and 11/21/2024.

In an interview on 11/27/2024 at 1:00 PM, S2DON confirmed the above mentioned findings.

2) Failure to accurately document observation check performance by the mental health techs (MHTs) on 9 (#1, #2, #4 - #10) of 10 (#1 - #10) patients.

A review of hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and last revised 07/31/2012 revealed in part: "Policy: All patients are monitored as to their location and activity at regular intervals. Procedure: A) Routine Levels of Observation: 1) all patients are monitored a minimum of once every 15 minutes. B) Special Levels of Observation: 1) Constant Observation: a. A patient is maintained in community areas where they can be observed at all times when the patient's condition requires a more intense level of ovservation and contact. b. Patients on a constant observation status must be accompanied if leaving the community area, e.g. to bathroom or to change clothes. c. Documentation of constant observation will be completed on observation sheets."

A review of hospital policy, "PC-1014: Patient Observation Record (15 Minute Check Sheet)," with an effective date of 07/10/2012 and last reviewed 12/27/2021 revealed in part: "Purpose: A designated MHT or other assigned staff will note and document patient's location and behavior every fifteen minutes on the Patient Observation Record."

Observations of video recorded on 11/21/2024 from 11:20 AM to 11:35 AM revealed the camera view of the interior of the nurses' station. Patient #3 was standing outside the nurses station and appeared to be asking S5LPN a question. The S5LPN retrieves a medical record and allowed the patient to observe a document in the medical record. Then S5LPN opens the door to the nurses' station to allow the patient to observe the document and remains in the open doorway while the patient observes the medical record. At 11:24:25 AM, S5LPN and Patient #3 appeared to be conversing as the patient attempts to lunge towards the nurse and enter the nurses' station. S5LPN was able to prevent the patient from entering and the patient retreats back slightly. S6RN was working at a nearby desk in the nurses station and begins to assist by helping to block the doorway as the conversation continues. S4MHT entered the nurses' station and stood behind the 2 nurses. Approximately 6 minutes elapsed with the nurses' station door in the open position, S5LPN and S6RN standing in the doorway and the patient approximately 1-2 feet in front of them. During this time frame, the video did not appear to physically show any attempt by S5LPN or S6RN to move the conversation away from the open nurses' station doorway. At 11:30:01 AM, Patient #3 is observed pushing her way through S5LPN and S6RN. S4MHT attempted to assist however Patient #3 overpowers all 3 staff and made her way to the exit door of the nurse's station leading the main entrance of the building. Another camera recorded Patient #3 exiting the building at 11:30:18 AM with S4MHT in pursuit. During the before mentioned time frame of the video reviewed, there were no other observable staff seen on video.

A review of the hospital records revealed the following staff scheduled at the time of the above mentioned elopement: S4MHT, S5LPN, S6RN, S7MHT, and S8MHT.

A review of the hospital census at the time of the above mentioned elopement revealed 10 patients with the current level of observations: 2 patients on line of sight (LOS) and 8 patients on every 15 minutes.

A review of Patients #1 - #10 medical record revealed:
Patient #1: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT;
Patient #2: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT;
Patient #3: Patient eloped;
Patient #4: Level of observation ordered: Line of Sight Observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT;
Patient #5: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT;
Patient #6: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT;
Patient #7: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT;
Patient #8: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S4MHT;
Patient #9: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S7MHT; and
Patient #10: Level of observation ordered: every 15 minute observation and the Patient Observation Record for 11/21/2024 at 11:30 AM revealed an observation check being performed by S8MHT.

The above mentioned observations of recorded video included the timeframe of the above mentioned observation checks on 11/21/2024 at 11:30 AM. S4MHT was observed on video being involved with Patient #3 prior to an elopement and leaving the building in pursuit of Patient #3 at 11:30 AM. The Patient Observation Logs revealed S4MHT initials indicating an observation on 3 (#1, #6, #8) of 10 (#1 - #10) patients at 11:30 AM. This surveyor did not observe any recorded video of S8MHT or S9MHT on the unit during the above mentioned time frame. The Patient Observation Logs revealed S7MHT initials indicating an observation on 3 (#4, #5, #9) of 10 (#1 - #10) patients at 11:30 AM and Patient #4 was a LOS. The Patient Observation Logs revealed S8MHT initials indicating an observation on 3 (#2, #7, #10) of 10 (#1 - #10) patients at 11:30 AM and Patient #2 was a LOS.

In an interview on 11/27/2024 at 10:35 AM, S1CEO confirmed the above mentioned observations checks were not performed. S1CEO indicated a video review by himself, confirmed S7MHT and S8MHT had left the building at 11:09 AM. S1CEO further confirmed the other 9 patients were not being monitored per physician orders.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by:
1) Brown stained ceiling tiles above the entry door of Room "i";
2) Failure to clean the ventilation system's return and exit vents of a grey, fuzzy substance resembling dust.
Findings:
1) Brown stained ceiling tiles above the entry door of Room "i"

Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed brown staining of 2 ceiling tiles above the entry door of Room "i."

In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings.

2) Failure to clean the ventilation system return and exit vents of a grey, fuzzy substance resembling dust.

Observations during a hospital walk-thru on 11/24/2024 from 1:30 PM to 2:30 PM revealed the hospital's ventilation system having a grey, fuzzy substance resembling dust accumulated on the vents located at the sky light of the unit's main hallway and at the entrance of Rooms "g," "m" and "p."

In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings.

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:
1) Failure to have documentation of a Master Treatment Plan in 1 (#2) of 3 (#1 - #3) patient medical records reviewed (See Findings Tag A1640);
2) Failure to address a change in condition in 1 (#3) of 3 (#1 - #3) patient's Master Treatment Plans reviewed (See Findings Tag A1640); and
3) Failure to address the findings of each contributing discipline on 1 (#3) of 3 (#1 - #3) patient's Master Treatment Plans reviewed (See Findings Tag A1640).

Based on medical record review and interview, the hospital failed to ensure social services records, including reports of interviews with patients, family members, and others, provided an assessment of home plans and family attitudes, and community resource contacts as well as a social history, were completed according to hospital policy. This deficient practice was evidenced by 2 (#2, #3) of 3 (#1 - #3) patient medical records reviewed having a psychosocial assessment being completed greater than 72 hours after admissions.
Findings:

A review of hospital policy, "PC-104: Assessments of Patients," with an effective date of 07/10/2012 and last revised on 12/27/2021, revealed in part, Procedure: The Department specific time frames for assessments are as follows: Psychosocial Assessment, SW (Social Worker), Within 72 hours of admission."

A review of hospital policy, "PC-405: Psychosocial Assessment," with an effective date of 07/10/2012 and no revisions, revealed in part: "Procedure: 1) A social work will conduct the psychosocial assessment within 72 hours of admission."

A review of medical records revealed the following completion times of the psychosocial assessment:

Patient #2 was admitted on 11/16/2024 at 4:15 AM. The psychosocial assessment was submitted on 11/20/2024 at 12:43 PM or approximately 104 hours after admissions.

Patient #3 was admitted on 11/21/2024 at 2:15 AM. The psychosocial assessment was submitted on 11/25/2024 at 3:26 PM or approximately 108 hours after admissions.

In an interview on 11/27/2024 at 11:15 AM, S2DON confirmed the above mentioned information.

Based on record review and interview, the hospital failed to ensure each patient had an individualized, comprehensive treatment plan based on the inventory of the patient's strengths and disabilities. This deficient practice was evidenced by:
1) Failure to have documentation of a Master Treatment Plan in 1 (#2) of 3 (#1 - #3) patient medical records reviewed;
2) Failure to address a change in condition in 1 (#3) of 3 (#1 - #3) patient's Master Treatment Plans reviewed; and
3) Failure to address the findings of each contributing discipline on 1 (#3) of 3 (#1 - #3) patient's Master Treatment Plans reviewed.
Findings:

1) Failure to have documentation of a Master Treatment Plan in 1 (#2) of 3 (#1 - #3) patient medical records reviewed

A review of hospital policy, "PC-501: Treatment Plans," with an effective date of 07/10/2012 and no revisions, revealed in part: "Policy: Each patient will have an individualized inter-disciplinary treatment plan developed under the direction of the psychiatrist. The comprehensive plan is initiated upon admission following assessments by various disciplines and will reflect the individual's clinical needs, condition, functional strengths and limitations. The treatment plan will be revised throughout the patient's hospitalization to reflect progress towards the treatment goals. Procedure: A) Problem List: Within 8 hours of admission, a problem list is initiated based on initial assessments. B) Initial Treatment Plan: 1) Within 24 hours of admission, a nurse completes an initial treatment plan that is based on an assessment of presenting problems, physical health emotional and behavioral status. C) Master Treatment Plan: 2) The Master Treatment Plan is based on the findings of each contributing discipline, which describe the patient's problems, strengths, clinical needs, and the patients goals for treatment. 3) The Master Treatment Plan contains: a) the patient's diagnosis; b) estimated length of stay; c) the problems to be addressed; d) the strengths to be utilized; e) Long-term goal of treatment for each problem; f) short term goals (objectives) of treatment for each problem, written in objective, and measurable terms with expected dates of achievement stated; g) staff interventions; h) discharged criteria. 7) The Master Treatment Plan includes planning specifically aimed at achieving the patient's goal(s) of treatment. 8) Each problem of the treatment plan is addressed, updated, revised, or resolved, and documented weekly during treatment team. 10) All newly identified patient problems or diagnosis will be incorporated into the plan of care and the treatment plan will be modified to reflect these changes."

A review of hospital policy, "PC-1201: Master List of Standards-NIMH," with an effective date of 07/10/2012 and no revisions, revealed in part: "Policy: C) Each patient must have an individual comprehensive treatment plan that must be based on an inventory of the individual patient's strengths and disabilities. 1) The written treatment plan must include: g) The plan should state: who is responsible for carrying out the plans by name and discipline; k) Interdisciplinary participation in treatment planning."

A medical record review of Patient #2 revealed an admission of 11/16/2024 through 11/22/2024. A form titled, "Master Treatment Plan Cover Sheet" was signed and dated by Patient #2 on 11/16/2024. The attending physician signed on 11/19/2024 indicating the Problem List, Treatment Plans, and Master Treatment Plan were reviewed. The other Participants included the signature of 2 RN's. There was no signature related to social services participation on this form. A form titled, "Treatment Team Plan Review," signed by the physician and nurse on 11/19/2024, but no social services signature indicating participation. The Psychosocial Assessment was submitted on 11/20/2024 (day after treatment team meeting). The medical record did not reveal the documentation of a Problem List or Master Treatment Plan.

In an interview on 11/27/2024 at 11:00 AM, S2DON confirmed the above mentioned information and further confirmed she contacted Social Services regarding the above mentioned information and S11DSS confirmed there was no documentation of a Problem List or a Master Treatment Plan being completed for Patient #2.

2) Failure to address a change in condition in 1 (#3) of 3 (#1 - #3) patient's Master Treatment Plan reviewed

A review of hospital policy, "PC-1-15: Elopement Risk Assessment and Precautions," with an effective date of 07/10/2012 and revised 08/25/2021, revealed in part: "Procedure: All protocols and precautions implemented for a patient at risk for elopement or escape shall be documented in the patient's treatment plan."

A medical record review of Patient #3 revealed an elopement occurring on 11/21/2024 at approximately 11:30 AM. A review of Patient #3 Master Treatment Plan did not reveal any documentation of the patient's change in condition or protocols and precautions implemented for a patient at risk for elopement or escape.

In an interview on 11/27/2024 at 10:30 AM, S2DON confirmed the above mentioned information.

3) Failure to address the findings of each contributing discipline on 1 (#3) of 3 (#1 - #3) patient's Master Treatment Plans reviewed

A review of hospital policy, "PC-1201: Master List of Standards-NIMH," with an effective date of 07/10/2012 and no revisions, revealed in part: "Policy: C) Each patient must have an individual comprehensive treatment plan that must be based on an inventory of the individual patient's strengths and disabilities. 1) The written treatment plan must include: a) a substantiated diagnosis; b) the responsibilities of each member of the treatment team; g) The plan should state: who is responsible for carrying out the plans by name and discipline; k) Interdisciplinary participation in treatment planning."

A medical record review of Patient #3 revealed an admission on 11/21/2024 at 2:15 AM. Patient #3 was admitted for a primary diagnosis of unspecified schizophrenia spectrum and other psychotic disorder and a secondary diagnosis of methamphetamine use disorder, moderate. The Master Treatment Plan was initiated on 11/21/2024 at 4:21 AM by S12RN and included: Problem #1: Mild Cognitive Impairment and Problem #2: At risk for increased anxiety. The Master Treatment Plan was not inclusive of the current diagnosis and did not reflect social services involvement after social services assessments.

In an interview on 11/27/2024 at 10:30 AM, S2DON confirmed the above mentioned information.