Observations
Based on a review of facility policies and client records, the facility failed to follow written procedures for the management of treatment and rehabilitation services for the client.
The facility's " Monitoring Health Status/Policy 3.9.25a " notes: " each client's vital measurements is taken by qualified operations staff at intervals set by either the program physician or the physician of the clients choosing. At a minimum, a client's vital measurements will be taken twice a day and before each observed medication pass."
Client #1 was admitted March 14, 2026, and was still active at the time of the inspection. A review of the client's medical records noted that on March 21, 2026, the facility was supposed to check the client's vitals three times; however, only one vitals check was documented.
Client #2 was admitted March 30, 2026, and was still active at the time of the inspection. A review of the client's medical records noted that on April 5, 2026, the facility was supposed to check the client's vitals twice; however, only one vitals check was documented.
These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
Organization leadership amended and updated the "Monitoring Health Status" policy to read "Vitals will be taken at minimum twice daily." Vitals will continue to be taken during med pass if the medication being taken requires vitals assessment (e.g. Clonidine et al.). The policy review number was updated to reflect the change.
All BHT, nursing, and clinical staff were made aware of the policy change via email as well as in person during pre-shift meetings during the week of 4/13-4/19.
Keystone Behavioral Health employs a third-party auditing company that reviews each chart for completion and compliance. One of the criteria for the auditors is to verify that each client's vitals were taken and documented twice daily. Reports from the auditing team are published on an internal dashboard that is transmitted to leadership staff via email as well as being accessible through a portal. Auditors will continue this practice to ensure vitals are being recorded correctly.
Departmental leadership will review all policies and procedures pertinent to their function once yearly and/or as needed when regulatory or operational information is changed/updated. In this instance, the Director of Nursing reviewed all nursing/medical policies and procedures to ensure they align with actual program processes as well as being compliant with regulatory standards. |