Nursing Investigation Results -

Pennsylvania Department of Health
WARREN GENERAL HOSPITAL
Patient Care Inspection Results

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WARREN GENERAL HOSPITAL
Inspection Results For:

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WARREN GENERAL 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 January 31, 2020, at Warren General Hospital, with additional documentation review concluding on February 6, 2020. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.



 Plan of Correction:


5100.15 (4) REQUIREMENT Treatment Plan Content and Availability:State only Deficiency.
5100.15 CONTENTS OF TREATMENT PLANS

(a) A comprehensive individualized plan of treatment shall:
(4) Result from the collaborative recommendation of the patient's interdisciplinary treatment team.
Observations:

Based on review of facility documentation, medical records (MR), and employee interviews (EMP), it was determined the facility failed to ensure that all interdisciplinary treatment team members signed the patient's Treatment Team/Care Plan in four out of seven closed medical records reviewed [MR3, MR4, MR7, and MR8].

Findings Include:

Review, at approximately 12:30 PM on January 31, 2020, of "Admission, Assessment, Treatment, Discharge, and follow-up," dated October 24, 2016, revealed, "... 11. Treatment Team and review meetings: ... c. Treatment team meetings must include (at minimum) the psychiatrist, a registered nurse or psychiatric social worker, and the patient. Family supports and other providers may participate with appropriate authorization; d. The physician is the Director of the treatment team and is responsible for the development, monitoring, and evaluation of the treatment plan. Input from additional team members is added as the plan and goals are developed; ..."

1. Review of MR3, at approximately 10:12 AM on January 31, 2020, of "Treatment Team/Care Plan Signature Page," no date, did not reveal signatures from a registered nurse or psychiatric social worker, the patient, or reasoning of absent signature from the patient.

2. Review of MR4, at approximately 10:32 AM on January 31, 2020, of "Treatment Team/Care Plan Signature Page," no date, did not reveal signatures from a registered nurse or psychiatric social worker, the patient, or reasoning of absent signature from the patient.

3. Review of MR7, at approximately 10:43 AM on January 31, 2020, of "Treatment Team/Care Plan Signature Page," no date, did not reveal signatures from a registered nurse or psychiatric social worker, the patient, or reasoning of absent signature from the patient.

4. Review of MR8, at approximately 11:00 AM on January 31, 2020, of "Treatment Team/Care Plan Signature Page," dated August 6, 2019, did not reveal a signature from the patient, or reasoning of absent signature from the patient.

At approximately 12:30 PM on January 31, 2020, EMP5 confirmed the above findings.




 Plan of Correction - To be completed: 04/15/2020

All treatment team meetings will include the psychiatrist, a registered nurse or a psychiatric social worker. Family supports and other providers may attend if permitted by the patient. The patient and all present will sign the treatment plan. Beginning March 2020, the manager of Behavior Health will complete monthly audits to assure that all required signatures are present on the form. Ten percent of inpatient behavioral health records will be sampled, and results will be documented on a spreadsheet. These results will be sent monthly to the Compliance Manager and will be presented bi- monthly at the Compliance Committee. These monthly audits will be completed until 100% compliance for 3 consecutive months is achieved. Additionally, the behavioral health staff will be required to review the WGH Policy for behavior health treatment plans and Pa Code 5100 requirements for education. This review will be documented by staff sign off and verified by the Behavioral Health Manager, and will be completed by March 30, 2020. The Behavioral Health Manager will be responsible for implementation of the plan of correction.

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