Initial Comments:
This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on March 15, 2024, at St. Clair Memorial Hospital, d/b/a St. Clair Hospital. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.
Plan of Correction:
5100.15 (3) REQUIREMENT
Treatment Plan Content and Availability
Name - Component - 00
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 was comprehensive for three of seven medical records reviewed (MR4, MR6, MR7).
Findings include:
Review of facility policy "Treatment Planning", last approved 01/2024, revealed: " ... The Interdisciplinary Treatment Plan is a written document that is used to identify each patient's clinical problems, needs, strengths, treatment goals, and barriers to those goals. The treatment plans are individualized for each patient, ... and they are modified as the patient's clinical condition warrants. ... In essence, the Treatment Plan serves as an organizational tool whereby the care rendered for each patient is designed, implemented, assessed, and updated in an orderly and clinically sound manner. ...".
Review of MR4 revealed the patient was ordered and received ECT on August 30, 2023, September 1, 2023, September 5, 2023, September 8, 2023, September 11, 2023, September 13, 2023, and September 25, 2023. Further review of MR4 revealed the Treatment Plan did not include the prescribed treatment modality of ECT.
Review of MR6 revealed the patient was ordered a Medication Over Objection on June 14, 2023 at 10:54 PM. The medication was given on June 14, 2023 at 11:15 PM. The order for the Medication Over Objection included instruction to include documentation regarding the use of Medication Over Objection in the Treatment Plan. Further review of MR7 revealed the Treatment Plan did not include the use of Medication Over Objection.
Review of MR7 revealed the patient was ordered for and was placed in restraints from December 28, 2023 through December 30, 2023. Further review of MR7 revealed the Treatment Plan did not include the use of restraints.
During review of facility medical records on March 15, 2024, between approximately 12:20 PM and 1:15 PM, EMP4 confirmed the above.
Plan of Correction:The Treatment Plan is to be tailored to the patient's diagnosis, medications, therapies and other suggested intervention and is to be utilized to monitor the patient's progress and outcomes.
The Interim Director of the Mental Health Unit will ensure the following education and action plan is completed timely to incorporate patients in restraint/seclusion, patients ordered to receive medications over objection and patients receiving Electroconvulsive Therapy (ECT) are included in the patient's Treatment Plan.
1. Education:
a. Psychiatric Department Registered Nurses will be provided education by May 17, 2023 instructing them on the proper process for entering restraint/seclusion, medications over objection, and ECT to the Treatment Plan of patients receiving these interventions/therapies.
The plan should be individualized to address the patient's specific needs and is to consist of the patient's problem, goal, intervention(s) and progress.
2. Action Plan:
a. The below problems, goals and interventions will be documented for patients receiving the above interventions/therapies at a minimum and the progress will be reviewed and documented weekly at a minimum. Additional patient individualized items should be added as indicated to obtain positive outcomes.
i. Patients in Restraint/Seclusion added to the Treatment Plan:
1. Problem: Restraint & Seclusion as evidenced by the behavior that warranted the use of restraint/seclusion
2. Goal: To be restraint Free
3. Interventions: Individualized interventions to prevent the need for restraint/seclusion in the future such as review of coping skills or distraction techniques.
4. Progress: Document at least weekly
ii. Patients ordered medications over objection
1. Problem: Medication non-compliance as evidenced by the medication(s) they are refusing to take.
2. Goal: To be compliant with taking medications
3. Interventions: Medication education
4. Progress: Document at least weekly
iii. Patients receiving ECT
1. Problem: Depressed Mood
2. Goal: Patient will state feeling less depressed as evidenced by improved affect, mood and motivation.
3. Intervention: Individualized interventions based upon the patient's needs.
4. Progress: Document at least weekly
3. Monitoring:
a. Starting in June 2024, the Psychiatric Department Leadership Team or designee will review all patient's medical records who required restraint/seclusion, medications over objection and ECT therapy weekly to ensure all have been added to the treatment plan as above and progress was documented at least weekly.
b. Monitoring will continue until 90% compliance is maintained for three consecutive months and then random audits will be conducted thereafter to ensure sustained compliance.
c. Results of the audit will be shared at the monthly Patient Safety Committee and reflected in the minutes which are shared with the Quality, Safety and Service Committee of the Board until 90% compliance is achieved for three consecutive months.
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