Nursing Investigation Results -

Pennsylvania Department of Health
JEFFERSON HOSPITAL
Patient Care Inspection Results

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JEFFERSON HOSPITAL
Inspection Results For:

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JEFFERSON 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 4, 2020 at Jefferson Hospital. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.



 Plan of Correction:


5100.15 (2) REQUIREMENT Treatment Plan Content and Availability:State only Deficiency.
5100.15 CONTENTS OF TREATMENT PLANS

(a) A comprehensive individualized plan of treatment shall:
(2) Be based upon diagnostic evaluation which includes examination of the medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the patients situation.
Observations:


Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a comprehensive individualized plan of treatment was based upon medical and psychological aspects of the patients situation for one of one medical records reviewed (MR1).

Findings include:

Review of facility policy and procedure "Treatment Plan" reviewed January 2018, revealed "1. Each patient shall have an individualized treatment plan that is based on assessments of his/her clinical needs. ... 3. ... c. all disciplines, medical, nursing, social service, occupational therapy and recreational therapy may add specific objectives and interventions to the treatment plan. ..."
1. Review of MR1 on February 04, 2020, revealed a physician order on August 30, 2019, "Forced Medication: Zyprexa inj 10 mg IM (intramuscular) 3 times a day prn for anxiety, may give if pt refuses PO zyprexa". Further review of the Treatment Plan revealed no documentation or discussion of the forced medication use.
Interview with EMP2 on February 4, 2020, at 10:00 AM confirmed the above findings.





 Plan of Correction - To be completed: 03/31/2020

1) A single point education lesson is being developed regarding the process and documentation for forced medications which contents will include:
a) The necessity for the Psychiatrist to document the justification for a forced medication order in the patient's Treatment Plan.
b) The discussion with the patient regarding the order for the forced medication order will also be reflected in the Treatment Plan.
2) Communication of the changes is being provided by the Behavioral Health Management Team during daily huddles beginning 2/17/2020.
3) The single point education lesson for the Treatment Team which includes the Psychiatrists, Registered Nurses, Social Worker and Case Manager will be reviewed and completed by 3/31/2020.
4) Because of the infrequency, all patient records with forced medication orders will be monitored by the Behavioral Health Management Team. The monitoring will begin on 4/01/2020 and continue until 10/01/2020 to ensure compliance.
5) The Behavioral Health Manager has responsibility of this plan and the compliance results will be reported to the Performance Improvement Oversight Committee on a monthly basis.

5100.53 REQUIREMENT Bill of Rights for Patients:State only Deficiency.
5100.53 BILL OF RIGHTS FOR PATIENTS

The following is the bill of rights for patients:
- You have the right to be treated with dignity and respect
- You shall retain all civil rights that have not been specifically curtailed by orders of court:
1. Unrestricted and private communication
2. Practice religion of your choice
3. To keep personal possessions, unless contraband
4. To handle your personal affairs
5. To participate in the development and review of your treatment plan
6. To receive less restrictive treatment
7. Right to be discharged as soon as you no longer need care
8. Not to be subjected to any harsh or unusual treatment
9. Right to be discharge with stipulations
10. To be paid for work
Observations:

Based on review of facility documentation, medical record (MR), and staff (EMP) interview it was determined the facility failed to ensure the patient treatment team determined in advance that a visitor or visitors would seriously interfere with the patient's treatment or welfare for one of one medical record reviewed. (MR6)

Findings include:

Review of policy and procedure " Inpatient Mental Health ... Visitor Guidelines " last reviewed January 2020, revealed " 3. Visitors are permitted upon review by the psychiatrist. The psychiatrist may order a visiting restriction based on the patient ' s clinical presentation, history or presenting problem. "
Review of facility " Bill Of Rights " dated December 2006, revealed " d. To receive visitors of your own choice at reasonable hours unless your treatment team has determined in advance that a visitor would seriously interfere with your or others treatment or welfare. "
Review of facility policy and procedure " Treatment Plan " reviewed January 2020, revealed " 1. Each patient shall have an individualized treatment plan that is based on assessments of his/her clinical needs. "
Interview with EMP1 on February 4, 2020, at 10:20 AM confirmed the above findings and revealed " I don ' t see any discussion about it(visitation restriction).
Interview with EMP2 on February 4, 2020, at 10:50 AM confirmed the above findings and revealed " It is our standard of practice if a patient is admitted with a positive drug screen without a prescription we restrict visitation. "
1. Review of MR6 on February 4, 2020, revealed a physician order on October 17, 2019, at 2214 "Visitation status - restricted". Further review revealed a physician order dated October 18, 2020, at 1809 "Visitation status - restricted ... only girlfriend can visit." Continued review revealed no documentation the patient treatment team determined in advance that a visitor or visitors would seriously interfere with the patient's treatment or welfare.

Interview with EMP1 on February 4, 2019, at 10:30 AM confirmed the above findings and revealed "I don't see any discussion about it[visitation restriction].

Interview with EMP2 on February 4, 2020, at 10:50 AM confirmed the above findings and revealed "It is our standard of practice, if a patient is admitted with a positive drug screen without a prescription we restrict visitation."




 Plan of Correction - To be completed: 03/31/2020

1) The visitor policy was reviewed by the Director of Nursing, Behavioral Health Nurse Manager, Behavioral Health Assistant Nurse Managers, Psychiatrists and Regulatory Lead. The policy will be updated by 2/21/2020 to reflect the appropriate changes regarding documentation in the treatment plan and communication provided to the patient regarding any visitor restrictions.
A single point education lesson is being developed which contents will include:
a) The updated visitor policy
b) The 5100.53 Bill of Rights for Patients
c) The necessity for the Treatment Plan to reflect the Psychiatrist's visitation order of
a. Restricted Visitors
b. Modification of a visitor restriction order
c. Visitor restriction order is lifted
2) On admission, visitation restrictions will be discussed with the patient and be reflected on the Master Treatment Plan otherwise restrictions will be reflected in the patient's treatment plan and reviewed during the treatment team meeting.
3) Communication of changes is being provided by the Behavioral Health Management Team during daily huddles beginning 2/17/2020.
4) The single point education lesson for the Treatment Team which includes the Psychiatrists, Registered Nurses, Social Worker and Case Manager will be reviewed and completed by 3/31/2020.
5) Patient records with restricted visitation physician orders will be monitored by the Behavioral Health Management Team beginning on 4/01/2020 and continue until 10/01/2020 to ensure compliance with documentation in the treatment plan.
6) The Behavioral Health Manager has responsibility of this plan and the results will be reported to the Performance Improvement Oversight Committee on a monthly basis.


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