HospitalInspections.org

Based on record review and interview, the facility failed to review treatment plans for effectiveness when clinically indicated for 1 of 5 patients reviewed (#4) as evidenced by:

Patient #4 had 7 incidents of self-abuse, kicking, spitting and biting staff and peers over 12 days without any update to the patient's Treatment Plan to protect the patient, staff and peers.

Findings include:

Patient #4

Record review of Patient #4's closed medical record revealed he was admitted on 4/23/14 with worsening behaviors and being sent home daily from school. He was throwing things at home, running away from home, attaching teachers and threatening to stab them.

Record review of Patient #4's "NOW ORDER FOR INVOLUNTARY EMERGENCY ADMINISTRATION OF PSYCHOACTIVE MEDICATION", Physician Orders and Nurses' Notes revealed the following:
4/25/14 at 5:00 p.m. Zyprexa zydis 10 mg. given for multiple episodes of banging his head, being verbally abusive, and physically aggressive to staff and peers. "Promptly attempt to isolate from others when aggressive specifically peers..."
4/27/14 at 8:15 a.m. - Patient #4 kicking walls in the hall and writing on the tables in the day room. Zydis 15 mg was given. At 10:10 a.m. the patient threw leggos at another patient and a physical altercation progressed. The nurse was bitten on the stomach while breaking up the altercation. Ativan and Benadryl were given.
4/29/14 at 8:15 a.m. - Patient #4 was "out of control, kicking throwing things around, cursing at staff, spitting on other peers..." Thorazine and Benadryl were given.
5/2/14 at 11:45 a.m. - Thorazine and Benadryl given for patient slamming doors, biting staff and banging his head against the wall.
5/3/14 - Thorazine and Benadryl given for banging his head, property destruction and "throwing things at other kids."
5/5/14 at 4:50 p.m. - Thorazine given and patient placed in seclusion for kicking, screaming and biting.
5/7/14 at 8:02 p.m. - Thorazine was given because patient was banging his head against the wall and biting staff.

Record review of Patient #4's Physician's Progress Notes dated 5/5/14 at 9 a.m. revealed the patient bit staff on the ankle yesterday and bit a peer on the nose and ankle. On 5/7/14 the patient spit at staff and peers and bit a peer and a staff person.

Record review of the facility's Occurrence Reports revealed the following:

4/30/14 at 8:45 a.m. Patient #4 pushed Patient #7 down on her left side. Ice was applied to the red area on left side and an x-ray was taken.

5/4/14 at 9:00 a.m. Patient #4 bit PT (Psychiatric Tech) #57 on the right ankle when she tried to break up a fight with him and another patient. The patient he was fighting with was not listed.

5/5/14 at 12:00 p.m. Patient #4 bit Patient #6 on the left leg. Record review of Patient #6's Nurses' Notes dated 5/5/14 revealed the patient was bitten by another patient, wound care was provided and a tetanus shot was given. "Will monitor and support for safety."

5/5/14 at 8:35 p.m. Patient #4 bit Patient #3 on the right lower jaw and put scratch marks on his neck.

Phone interview on 8/13/14 at 3:15 p.m. with Patient #3's family member, she said her son had told her on 5/3/14 that a boy had bitten him on the left elbow and was fighting with him. The boys name was Patient #4. The family member called the facility and talked with a nurse who did not know anything about the incident. The nurse said she would take the information to the meeting with other nurses and get something done. Then she got a call on 5/5/14 that her son had been bitten on the cheek. She said she took her son out of the facility and took him to Hospital #2.

Record review of Patient #3's Hospital #2 Forensic Nursing Team consult dated 5/6/14 at 3:04 a.m. revealed the following:
"...+ (positive) facial pain on palpation to R (right) cheek - circular abraded area noted, patient states, 'he bit me'...+ neck pain on palpation to posterior neck - cervical spine area - has two linear red abrasions noted states, 'he scratched me' tender to palpation...circular areas of discoloration noted to upper extremities, circular faint reddened area with abrasion in middle noted to L (left) elbow - patient states, 'he tried to bit me there',...patient was already being admitted for IV antibiotics related to facial human bite."

Record review of Patient #4's Master Treatment Plan & Nursing Care Plan dated 4/23/14 revealed the his Axis I-II problems were anger management problems and aggressive behaviors. For anger management, the patient agreed to talk only when he had calmed down and "no hitting, biting, throwing things." The patient was to work to increase insight about behaviors, increase self-control, and decrease violence. For Physical Aggression, threw scissors at Dad, threatened to stab mother, attacked teachers and biting people, the long-term goal was to stabilize mood and behaviors. The short-term goal was to practice walking away from conflict and talk when calmed down. The target dates were 4/30/14. The Treatment Plan and Nursing Care Plan had not been updated since.

Further record review of the patient's Physician's Orders revealed no order for one on one monitoring of the patient. There was no documentation of weekly IDT (interdisciplinary team) meetings.

Record review of the facility's Policy and Procedure for TREATMENT PLAN - PROTOCOL FOR THE USE OF THE MULTIDISCIPLINARY FORMAT dated 9/17/12 revealed the following:
"Phase III Plan of Care Development: Ongoing Treatment Review...
The representatives will meet weekly to discuss, review, and update the plan. This will include presentation of their update summary, a review and discussion of goals, objectives and interventions on each problem-specific plan of care....
The documentarist and/or responsible staff will then revise and/or update the problem specific plans of care. This will include all changes in goals, objectives and interventions, revised target dates or closure of a problem..."

Interview on 8/13/14 at 12:30 p.m. with RN #54, she was asked about one on one monitoring. She said the nurses had the authority to ask for one on one monitoring or to contact the supervisors about getting one on one monitoring. She said she did not know why there was no order for one on one monitoring. She said they are supposed to call the patient's physician and do what he ordered. She said the facility did not have weekly IDT meetings to discuss patient behaviors and goals.

Interview on 8/13/14 at 1:55 p.m. with CNO (Chief Nursing Officer) #52, she said she was not working at the facility in May 2014. She said the facility should have weekly IDT meetings. She said she would think the facility needed to update the Treatment Plan when a patient exhibited aggressive behaviors toward peers. She said it sounded like Patient #4 needed one on one monitoring. She was asked to look at Patient #4's medical record to see if the Treatment Plan was updated and to find any documentation of weekly meetings. She was not able to find any updates or meetings. After reviewing his record, she said again that Patient #4 needed to be put on one on one monitoring because he was too unpredictable with his history of aggression.

Record review of the facility's incident log revealed no investigations of any of the above incidents by Patient #4.

Record review of the facility's Policy and Procedure for RECOGNIZING AND REPORTING SUSPECTED CHILD, ADULT, DISABLED PERSON OR ELDERLY ABUSE/NEGLECT/EXPLOITATION dated 9/17/12 revealed the following:
"POLICY:...
Cambridge Hospital shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, other patients, visitors or family members...All allegations, observations or suspected cases of abuse, neglect or exploitation that occur in the hospital will be investigated by the hospital..."

Record review of Patient #3's Patients' Rights dated 5/1/14 revealed, "Not be subjected to verbal, physical, sexual, emotional or financial abuse; harsh or unfair treatment."

****PLEASE NOTE: The facility had recently been cited on 6/18/14 for tag 502 - patient right to be in a safe environment and tag 523 - for abuse and neglect. The facility is currently developing an acceptable Plan Of Correction for these deficiencies.