Pennsylvania Department of Health
FORBES HOSPITAL
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FORBES HOSPITAL
Inspection Results For:

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FORBES HOSPITAL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on February 28, 2024, at Forbes Hospital. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.

Plan of Correction:

5100.11 (a)(b)(c)(d) REQUIREMENT Adequate Treatment:

TREATMENT

5100.11 Adequate Treatment
(a) Provided by facility
(b) Use of community
(c) Treatment reviewed
(d) Funding requirements

Observations:

Based on review of facility documents, medical records (MR) and staff interviews, it was determined the facility failed to provide adequate treatment by failing to follow it's policy for pre-electroconvulsive therapy (ECT) lab studies for two of three medical records of inpatients receiving ECT that were reviewed (MR7 and MR8).

Findings include:

Review of facility policy "ECT - Provision of ECT, 3552 POL-5422324", last approved 3/3/2023, revealed: " ... Pre-ECT Lab Studies: required for all patients: ... [Magnesium] ...".

Review of MR7 revealed the patient was ordered and received ECT on November 20, 2023, November 22, 2023, November 24, 2023, and November 27, 2023. Further review of MR7 revealed a Magnesium level was obtained on November 28, 2023.

Review of MR8 revealed the patient was ordered and received ECT on August 16, 2023, August 18, 2023, August 21, 2023, August 23, 2023, August 25, 2023, August 28, 2023, August 30, 2023, September 1, 2023, and September 5, 2023. Further review of MR8 revealed no Magnesium level was obtained within six months prior to initiation of these treatments.

During review of facility medical records on February 28, 2024, between approximately 12:30 PM and 1:45 PM, EMP2, EMP8, and EMP11 confirmed the above.

Plan of Correction - To be completed: 04/14/2024

The Director of Nursing is ultimately responsible for this plan of correction. Education will be given to all ECT staff on the requirement of pre-electroconvulsive therapy lab studies required per policy "ECT � Provision of ECT, 3552 POL-5422324". Upon receipt of a patient for treatment, the requirement is to ensure that the following labs have been completed within 6 months of treatment: CBC with Differential, Basic Metabolic Panel, Calcium, Magnesium, and Urinalysis. All required labs will be verified before proceeding with ECT. Education will be completed prior to the initiation of the audit.

Auditing of the process will begin on March 25th, 2024, and will be 10 records/month. This audit will continue until compliance with all components is 100% three (3) consecutive months. Report of compliance will be at the Performance Improvement Oversight Committee meeting monthly and the Behavioral Health meeting monthly.

5100.15 (3) REQUIREMENT Treatment Plan Content and Availability:

5100.15 CONTENTS OF TREATMENT PLANS

(a) A comprehensive individualized plan of treatment shall:
(3) Set forth treatment objectives and prescribe an integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives.

Observations:

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the treatment plan reflected an integrated program of therapies, specifically electroconvulsive therapy (ECT), for three of three medical records of inpatients receiving ECT that were reviewed (MR6, MR7, MR8).

Findings include:

Review of facility policy "Interdisciplinary Treatment Plan and Meeting, 2879 POL-6151784", last approved 4/20/2023, revealed: " ... Overview Statement It is the policy of the behavioral Health Unit that every patient admitted to the unit will have an individualized treatment plan. ... 1. To systematically collate all pertinent data to reflect the patient's needs based on multidisciplinary assessments. 2. To identify and provide interventions and appropriate treatment modalities ...".

Review of MR6 revealed the patient was ordered and received ECT on October 23, 2023, October 25, 2023, October 30, 2023, November 1, 2023, and November 6, 2023. Further review of MR6 revealed the treatment plan did not include the prescribed treatment modality of ECT.

Review of MR7 revealed the patient was ordered and received ECT on November 20, 2023, November 22, 2023, November 24, 2023, November 27, 2023, December 4, 2023, and December 6, 2023. Further review of MR7 revealed the treatment plan did not include the prescribed treatment modality of ECT.

Review of MR8 revealed the patient was ordered and received ECT on August 16, 2023, August 18, 2023, August 21, 2023, August 23, 2023, August 25, 2023, August 28, 2023, August 30, 2023, September 1, 2023, and September 5, 2023. Further review of MR8 revealed the treatment plan did not include the prescribed treatment modality of ECT.

During review of facility medical records on February 28, 2024, between approximately 12:30 PM and 1:45 PM, EMP2 confirmed the above.

Plan of Correction - To be completed: 04/14/2024

The Director of Nursing is ultimately responsible for this plan of correction. Education will be given to all Behavioral Health multi-disciplinary staff on the requirement to systematically collate all pertinent data to reflect the patient's needs based on multidisciplinary assessments, to identify and provide interventions and appropriate treatment modalities, and to assess inpatient progress: and to identify follow up needs per policy "Interdisciplinary Treatment Plan and Meeting, 2879 POL-6151784".
During treatment plan, the interdisciplinary treatment team will ensure patients receiving ECT will have the prescribed treatment modality of ECT included in the treatment plan. Education will be completed prior to the initiation of the audit.

Auditing of the process will begin on March 25th, 2024, and will be 10 records/month. This audit will continue until compliance with all components is 100% three (3) consecutive months. Report of compliance will be at the Performance Improvement Oversight Committee meeting monthly and the Behavioral Health meeting monthly.

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