Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010001	(X3) Date Survey Completed 08/24/2017
Name of Provider or Supplier Southeast Health Medical Center	Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A0396

NURSING CARE PLAN
CFR(s): 482.23(b)(4)

The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan

This STANDARD is not met as evidenced by:
Based on review of facility policy, medical records and interview with staff, it was determined the facility failed to ensure an updated treatment plan was implemented and updated for a suicidal patient according to the facility policy. This affected 1 of 3 medical records reviewed, including Patient Identifier (PI) # 1 and has the potential to negatively affect all patients admitted to the Behavioral Medicine Unit (BMU) / Behavioral Health Services (BHS). Findings include: Facility Policy/Procedure: Treatment Planning-Behavioral Medicine Effective Date: 9/1/2009 Policy: Each patient admitted to the Behavioral Health Services (BHS) will have an Initial Treatment Plan initiated on admission. Each discipline will add their specific interventions. An Interdisciplinary Treatment Plan will be developed with the patient, physician, nurse and therapist. After the Interdisciplinary Treatment Plan is complete, a review will be held weekly to re-evaluate the patient's progress and update the Interdisciplinary Treatment Plan. Purpose: To identify the purpose of the multidisciplinary treatment planning team sessions and guidelines. Procedure: 1. The multidisciplinary treatment planning sessions meet three times a week. 6. Notes or updates of results of the discussion are documented on the interdisciplinary treatment review. ****** Facility Scope of Care Behavioral Health Services Revision Date: 1/17 The inpatient center is divided into specialty programs. Three North treats the most acute patients typically with diagnosis's of psychosis, schizophrenia, bipolar disorders, agitation, and other patients requiring a high level of supervision and redirection. The program consists of group process, education and activity therapy. Standard of Care (practice guidelines and professional performances). Patient care will be administered according to the nursing process outlined in the Patient Care Services Policy and Procedure Manual and Standards of Psychiatric Nursing as established by the American Nurses Association. The Master Treatment Plan is the center of the patient's treatment and shall be based on collected data, nursing assessments, social history, the physician's history and physical, psychological testing, etc. The Master Treatment Plan will be implemented using this information to identify patient problems, goals, objectives, treatment modalities utilized, and estimated time frames. Treatment planning will be performed on all patients and updates to the Master Treatment Plan will be documented. 1. Patient Identifier (PI) # 1 was admitted to the facility on 5/14/17 with Auditory Hallucinations, Psychosis and Suicidal Ideations. PI # 1 presented to the Emergency Department (ED) on 5/14/17 with complaints of, "... can't remember anything... back hurts so bad and I don't know if it is my body or just life in general..." The patient stated he/her had suicidal ideation, security was notified and suicide precautions were in place. On 5/14/17 at 5:57 AM, while the patient was in the ED, the Technician was present in the room while security was called away when the patient grabbed (his/her) purse and began to put on makeup. The patient was digging through the purse and became upset when the Technician saw something silver that was concealed by the bag. The staff member called for help and the patient proceeded to try to put a pocket knife to his/her left wrist and cause harm to self. With security's help, all of the patient's belongings including the knife were removed and the patient was placed in a hospital gown. The patient was subsequently admitted to the facility in the BMU. Review of the Psychiatric Evaluation History and Physical dated 5/14/17 revealed the patient's chief complaint was, "I hear him." The psychiatrist documented, "... Per ER (Emergency Room), patient complaining of hearing 2 or 3 different people inside of (him/her), the voices... are (his/her) own and is just different people that live in (him/her)... the voices tell (him/her) to kill (self). Patient has suicidal ideation. Patient reports multiple suicide attempts in the past and stated... had tried to overdose and has tried the hang (self) on 2 occasions. Patient denied any visual hallucinations... denied homicidal ideation... As of today... patient very irritable, we need to encourage (him/her) several times to finish the evaluation. Patient reported hearing all kinds of things, like... own voice telling (him/her) different things including telling (him/her) to kill (self)... Patient reported paranoia, said, "they are talking about me."... reported depression... no energy, poor appetite, and said, "he tells me don't eat."... said the person inside of (him/her) is with (him/her)... reported suicidal thought, said, "you don't need a plan, you just do it..." Further review of the Psychiatric History and Physical dated 5/14/17 revealed, "... Mental Status Examination: ... poorly groomed, not well cooperative, with poor eye contact... psychomotor agitation... Mood: Depressed. Affect: Very irritable, constricted, labile. Thought process and association: Illogical and loose. Thought content: ... reports auditory hallucinations, paranoia,,, suicidal thought. Insight: Poor. Judgement: Poor... Concentration and attention span: Poor... Differential Diagnoses: ... Substance-induced psychotic disorder... Methamphetamine abuse... Rule out gender identity disorder... Rule out schizophrenia... Rule out mood disorder... Treatment Plan: 1. Safety: Admit the patient to psych inpatient unit, start q15 minute observation, and monitor patient's vital signs closely..." Review of the Interdisciplinary Master Treatment Plan dated 5/14/17 and signed by the Interdisciplinary team on 5/17/17, revealed no documentation suicidal ideation was identified as a problem and there was no documentation of interventions related to suicidal ideation. Review of the Psychosocial Assessment dated 5/18/17 revealed the Licensed Professional Counselor (LPC) documented, "... (patient) stated was feeling hopeless and suicidal on admission. Pt (patient) continues to report... is suicidal... having auditory hallucinations, reporting "they" won't let (him/her) eat... Pt was seen by staff attempting to eat and having a verbal altercation with another personality (he/she) calls "William" in which "William" told (patient) not to eat and then pt hit self when attempting to take a bite... Pt did state if (he/she) left the hospital... would kill self..." Review of the Physician Progress Note dated 5/21/17 revealed the physician documented, "...Tells me (he/she) is not a danger to (self) or others. In group revealed when (he/she) came here (he/she) is going to kill (self)..." The patient denied suicidal ideation/homicidal ideation (SI/HI). The physician circled "SI with plan" and further documented, : told group (he/she) planned to kill (self) after d/c (discharge)..." Review of the Physician Progress Note dated 5/22/17 revealed the Psychiatrist documented, " ... Mental Status Examination ... mood depressed ... continued to have suicidal ideation ... had thoughts of trying to hang (self) ... asked (him/her) about voices ... denied that (he/she) heard voices and stated "they are my own stupid thoughts." (Patient) did make some self-deprecatory remarks ... reportedly made a comment in group therapy that (he/she) was going to kill (self) after ... got discharged ..." Review of the Physician Progress Note dated 5/23/17 revealed the Psychiatrist documented, " ... Subjective ... patient remains depressed ... continues to have suicidal thoughts which include sticking something in a light socket or throwing (his/her) blanket over the door and trying to hang (self) ... Mental Status Examination ... appeared depressed, though there was little mood reactivity. Speech was limited to answering questions ... There was no suicidal or homicidal ideation present ... was a little worried as to what was going to happen to (him/her) because ... was "homeless" ... On the one hand ... felt ...needed to be in a group home. "I do not trust myself. I make bad decisions"..." Review of the Physician Progress Note dated 5/24/17 revealed the Psychiatrist documented, " ... the patient appears a little more depressed today than yesterday ... does show a little bit of mood reactivity ... is appearing more depressed ... affect was euthymic and mood depressed ... There was no suicidal or homicidal ideation present. When I asked ... about suicidal thought, (he/she) stated "I have put them on hold ... When I asked (him/her) what (he/she) meant by that ... (patient) indicated that previously (he/she) would kill (self) if HIV (human immunodeficiency virus) positive ... now ... willing to see what it is like living with HIV and taking medication, and not automatically stating (he/she) would kill (self) ..." Review of the Physician Progress Note dated 5/25/17 revealed the Psychiatrist documented, " ... Subjective ... affect is less flat, mood still depressed, but less so ... not psychotic ... does report having suicidal thoughts ... not sure whether (he/she) want to live or not ... denies, however, this has anything to do with being HIV positive and states ... has been feeling this was for some time ... at one point, (patient) indicated ... wanted to be discharged either today or tomorrow. I pointed out ... that first off, (he/she) was having suicidal thoughts, so I was not going to discharge (him/her). Secondly ... (patient) was court ordered and has to go back to court next week and the judge would have to release (him/her) ... (Patient) then looked at me and smirked and said "he did not tell me that" ... we did discuss it briefly yesterday ... (patient) was not interested in hearing about it and elected not to go to (his/her) court hearing ..." Review of the Physician Progress Note dated 5/26/17 revealed the Psychiatrist documented, " ... Subjective ... reports having had fleeting suicidal thoughts, but not having thoughts, but (he/she) did not want to live ... is not psychotic ..." Review of the Physician Progress Note dated 5/27/17 revealed the Psychiatrist documented, " ... came to meet with the patient, it was after lunch ... lying on ... bed and was teary ... did state ... had been hearing voices telling (him/her) to bust (his/her) way out of the hospital ... affect is euthymic, mood depressed and teary ... had been having suicidal thoughts. Though no specific plan or intent ... is feeling a little tired of being in the hospital ..." Review of the Physician Progress Note dated 5/28/17 revealed the Psychiatrist documented, " ... does feel a little anxious at times ... had a little more difficulty sleeping ... has not been hearing voices ... has not had any suicidal ideation or behavior ... is agreeable to going to the group home when there is an opening ... is willing to "jump through the hoops" to get there ..." Review of the Physician Progress Note dated 5/29/17 revealed the Psychiatrist documented, " ... There was no suicidal or homicidal ideation present ... did report having a lot of difficulty sleeping last night and this is 2 nights in a row ... has had problems sleeping ..." There was no documentation in the medical record the patient's above documented behaviors were communicated to the nursing staff. Nor was there documentation those behaviors were addressed by the Interdisciplinary team in the treatment plan or that additional safety interventions were implemented. Review of the Therapist Documentation note dated 5/30/17 at 9:30 AM revealed, "Dr (doctor) and this writer met with pt (patient) in the hall... (patient) asked about court and this writer advised that (he/she) was not on the docket for today and pt responded with, "I am not going to stay here two more days"... This writer advised that I would contact the court and see if I could get (him/her) on the docket for this afternoon and would let (him/her) know if it changes..." This note was documented on 5/30/07 at 2:42 PM. Review of the Physician Progress Note dated 5/30/17 revealed the Psychiatrist documented, " ... When I walked on the unit this morning, around 9:30 AM, the patient approached me to ask about court. I pointed out that (he/she) was not on the docket for today. The case manager indicated we could try to get (him/her) on the docket for today ... (Patient) indicated they would talk with (him/her) a little later ... (Patient) walked away and mumbled something about (he/she) was not going to spend 2 more days in the hospital. At 11:23 in the morning ... received a call from a case manager indicating that the patient had been found in (his/her) room in apparent hanging attempt, unresponsive. Resuscitation efforts were not successful and the patient was subsequently pronounced dead ..." This Physician Progress Note was dictated on 5/30/17 at 5:42 PM.