Download A Comprehensive Evaluation of Georgia`s State Hospital Services

A Comprehensive Evaluation of Georgia’s
State Hospital Services
Requested by and provided to:
Division of Mental Health, Developmental Disabilities
and Addictive Diseases
Georgia Department of Human Resources
Submitted by:
Peter F. Buckley, MD and Nannette M. Lewis, MPH
Project Co-Directors
Department of Psychiatry and Health Behavior
Medical College of Georgia
December 2007
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TABLE OF CONTENTS
1. Executive Summary ................................................................... Page 3
2. Background and Context ........................................................... Page 6
3. Survey Method...........................................................................Page 9
4. Survey Team Composition....................................................... Page 11
5. Individual Facility Reports ........................................................ Page 15
Savannah .............................................................................. Page 15
Atlanta ................................................................................... Page 20
ECRH Augusta...................................................................... Page 31
SWRH Columbus.................................................................. Page 44
CSH Milledgeville.................................................................. Page 55
NWRH Rome ........................................................................ Page 75
SWSH Thomasville ............................................................... Page 87
6. System Report ......................................................................... Page 95
7. Limitations of this Audit .......................................................... Page 117
8. Concluding Remarks.............................................................. Page 118
9. Bibliography ........................................................................... Page 120
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EXECUTIVE SUMMARY
The Department of Psychiatry and Health Behavior at the Medical College of
Georgia (MCG) began discussions with the Division of Mental Health,
Developmental Disabilities & Addictive Diseases (Division) within the Georgia
Department of Human Resources (DHR) in late 2006 regarding the delivery of
inpatient mental health services within the state institutions. MCG was requested
to conduct an audit of each individual facility as a quality improvement process
and to provide feedback recommendations on the provision of care in each
facility and in the state hospital system as a whole.
Prior to initiation of the site visits, MCG and the Division worked together to
develop an audit tool, outline needs and desired outcomes, and define survey
methods. In addition, MCG met with consumer and advocacy groups to hear
global concerns on the delivery of care in the state hospitals.
Facility audits began in March 2007 and continued through September 2007, with
a frequency of one site visit per month. The reports on each facility were
summarized into major categories to include: Chart Organization and Content,
Programming, Physician Documentation, Medical Management of Patients,
Quality Initiatives, Treatment Team/Treatment Planning, Safety and the
Environment of Care, Staffing, Utilization Management, Seclusion and Restraint,
Patient and Family Issues, Training and Staff Development, Risk Management
and Nursing Practices.
Findings specific to each hospital were made available to each facility within 30
days of the site visit, and were included in the primary reports. While the
summary reports on each facility are included in this final system report, the main
purpose of this document is to identify consistent findings, examine system-wide
challenges and opportunities for improvement and make recommendations for
organizational enhancement and development in the provision of care.
This final system report contains over 40 specific recommendations. Many
pertain to areas related to staffing issues, including the recruitment, retention and
training of mental health professionals, staffing mix and staffing levels. Other
recommendations involve programming, risk management and quality initiatives,
charting and medical record maintenance, medical management, centralization,
standardization, and patient and family issues. For convenience in reporting, in
this Executive Summary, the major recommendations are divided into categories
of clinical quality, administrative structure, and system resources.
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Clinical Quality
1. The Division should develop quality initiatives in collaboration with consumers
and providers; these initiatives should be positive and proactive, with
benchmarks established by national standards. Action plans should be
implemented by providers, and supported and monitored by management.
Quality initiatives must contain components of education, networking, and
technology and be organized and orchestrated throughout the Division, to
create a culture of quality.
2. The system as a whole needs to embrace the recovery model, employing
both patient advocates and peer specialists for staff education and
enhancement of treatment programs.
3. The Division should incorporate informed patient-centered decision making
as a standard of care across the system. This will require a system-wide
policy, sufficient numbers of trained and competent staff, and a standardized
practice of communication, collaboration and the participation of patients and
family members on an individual and Advisory Board level.
4. The Division should continue full implementation of the MANDT system, with
ongoing analysis of the need for alternative/additional resources for safe and
effective patient/milieu management in the absence of seclusion/restraint
interventions.
5. The Division should continue efforts to insure that active programming is
being scheduled and provided both on the units and in the Treatment Malls,
with an appropriate balance between therapeutic and recreational activities.
6. The Division should encourage the development of facility Medical Staff
Bylaws that set standards for the qualifications expected for the level and type
of care provided, including general, forensic, and child/adolescent credentials;
the bylaws should also include provisions for the supervision of residents who
provide on-call services. This should also support the strategic use of expert
consultants from the community.
7. The Division should develop a comprehensive program for drug/alcohol
treatment, including the recognition and treatment of medical complications
commonly associated with substance use. Drug/alcohol treatment/education
should be made available to all patients hospitalized for psychiatric reasons.
8. The Division should develop or strengthen affiliations with state medical
schools and universities to provide training and education about best
practices in recognition, early detection and treatment of medical conditions,
and especially to support recruitment and retention.
9. The Division should provide central office medical resources for expedited
and thorough investigations of critical incidents. Analysis of trends and
patterns of these incidents should lead to the design and implementation of
risk reduction strategies based on the results.
10. The Division should continue to pursue best practices in the use of
medications and in the monitoring of their effects.
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Administrative Structures
1. The Division should create a positive culture and an affirmative work
environment in the facilities through supportive supervision, constructive
mentoring and a collaborative work relationship with hospital-level
administrators and mid-level managers.
2. The Division should create 3-4 state-level associate medical director positions
to focus on key areas such as forensics, medical oversight, risk management,
developmental disabilities, child/adolescent, etc.
3. The Division should develop and implement a standard format and
organization for all hospital medical records. This effort should be completed
in a timely manner and be a joint effort between Central Office and the
facilities. The Division should also investigate the use of new technologies
and set a target date for the implementation of a fully electronic medical
record.
4. The Division should adhere to a system-wide Policy and Procedure Manual
that has been developed and approved by the Division and all Hospitals; this
manual should provide broad guidelines for important areas and should not
be highly detailed
System Resources
1. The Division should conduct a comprehensive salary survey to determine
current salary scales for all professional staff, followed by a restructuring of
salaries to 70th percentile – 80the percentile within the regional market scales.
2. The Division should employ its own professional recruiters to attend national
conventions and meetings to seek out and attract professionals whose
interests include inpatient treatment.
3. The Division should conduct a thorough analysis of the salary, education, and
training requirements of the Health Science Technician in order to make them
comparable to the job responsibilities and risk factors associated with this
position.
4. The Division should ensure that each facility have a sufficient number of
qualified, board-certified primary care physicians, with at least one at each
site, to provide consulting and routine medical care for psychiatric inpatients.
In facilities with significant DD populations, primary care physicians may act
as the primary attending for DD patients, with psychiatric consultation; these
facilities will require additional primary care physicians to meet the demands
of this challenging role as well as the more typical consultation role for
psychiatric patients.
The development, implementation, and delivery of this audit required the input,
cooperation, and support of many individuals, groups and organizations. It is
intended to provide a framework for many constituents to contribute to the
successful improvement of the system, and to support the Division’s commitment
to quality improvement and enhancement of the delivery of care to those in
Georgia in need of public mental health services.
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BACKGROUND AND CONTEXT
The Georgia Department of Human Resources, Division of Mental Health,
Developmental Disabilities, and Addictive Diseases (Division) is the provider for
Georgians in need of public mental health services. Inpatient acute care is
provided at seven facilities, which are geographically-based to serve the diverse
rural and metropolitan population of the state. All facilities provide adult inpatient
services, both acute and long term. Some facilities also provide acute inpatient
care for disturbed children and adolescents. Furthermore, specialized services
within some of these facilities include inpatient forensics, long-term care for
individuals with developmental disabilities, and the management of complex dual
diagnosis situations.
The inpatient population served constitutes a disadvantaged sector of our
community. Clinically, this population is characterized by severe mental illness,
(predominantly psychotic disorders and mood disorders), inordinately high rates
of co-morbid physical illnesses and poor psychosocial supports. Admissions to
the state facilities are often precipitated by injurious behaviors to self or others
and are frequently complicated by abuse/dependence on alcohol or illicit drugs.
As a subgroup of all psychiatric patients who receive public mental health
services, inpatients are a particularly challenging patient group. Clinical
complexities of treatment include management of suicidal and aggressive
behaviors, detection and management of co-morbid substance abuse problems,
detection and management of co-morbid medical conditions, appropriate
prescription and monitoring of psychiatric medications and appropriate
prescription and monitoring of non-psychiatric medications. These same clinical
complexities arise and are amplified further in the specialty populations of
disturbed youth, forensics and developmentally disabled.
Service complexities that are associated with the provision of care in such patient
populations include the adequate assessment and support services for physical
illnesses, the requirements for comprehensive multidisciplinary care with
attention to both medical and psychiatric health needs, requirements for effective
communication and skilled documentation among several levels of healthcare
professionals, and the importance of integrated (medical-psychiatric), and
coordinated (inpatient-to-outpatient) treatment planning.
The seven state hospitals operate within their regions and each has its Medical
Director and Hospital Administrator, with centralized oversight of services jointly
through the office of quality assurance and the Division Medical Director's office.
Ongoing discussions began in late 2006 with the Department of Psychiatry and
Health Behavior at MCG, focusing on the advantage of a timely, independent and
external evaluation of clinical care throughout the system. The goal of the
evaluation was to carefully examine medical and psychiatric care in the state
hospitals, as well as the processes for integrating and monitoring this care. An
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audit conducted at each hospital would allow an evaluation of individual facilities,
with immediate reports of observations and findings. The additional value of a
seven-facility coordinated survey, however, would be the ability to make systemwide comments and recommendations, to identify strengths found within the
system and to address common opportunities for improvement.
Though part of a larger system, each hospital was unique, as each varied
significantly in size, services, populations served and catchment areas. It is
helpful to understand these variances to fully appreciate individual facility and
system challenges and recommendations.
Georgia Regional Hospital of Savannah is the smallest of the seven facilities,
with approximately 100 beds, and is one of two state facilities that does not serve
the developmentally disabled (DD) population. It has three distinct units,
consisting of a short and long term acute adult mental health unit and a forensic
unit. The facility had a very high census on the initial day of the audit, as the
acute unit was over capacity and another 14 additional acute “boarders” had
been added to the long-term unit.
Georgia Regional Hospital - Atlanta has approximately 350 beds in eight
distinct units. Approximately 120 Adult Mental Health beds are divided between
three units, one of which is designated for longer-term stays. All of these units
are typically over capacity. The Adolescent Acute Unit, one of only two in the
state, has 28 beds. Two Forensic Units house 90 beds. The remaining beds are
divided between two units serving the developmentally disabled (DD), one of
which is a Skilled Nursing Facility (SNF). In terms of admissions, the Atlanta
hospital is the busiest in the state.
East Central Regional Hospital in Augusta, the second largest facility in the
state, has over 600 beds, most dedicated to management of the developmentally
disabled. The hospital is divided between two campuses, the Gracewood and
Augusta campus. Gracewood beds are exclusively for the developmentally
disabled and are located in three buildings, Birch, Redbud and Camellia. These
are further divided into 5-6 units of about 20 individuals each. Patients are
grouped by level of functioning and required care. Camellia houses those with
the greatest physical needs in two Skilled Nursing Units.
The Magnolia, Holly and Spruce Buildings on the Augusta Campus make up the
100 bed Azalea treatment center for developmentally disabled. The Forensic
Unit adds 52 beds and the Adult Mental Health Unit has 64 beds.
West Central Regional Hospital in Columbus has just under 150 beds and is
one of two state facilities that has no beds dedicated to developmentally disabled
patients. It is separated into four units: a 40 bed forensic unit, two short-term
mental health units and one longer term mental health unit which also houses
overflow forensic patients. On the day of the audit, the facility was over capacity
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and was preparing to go on diversion if more admissions presented. In less than
one month from the date of the survey, there were plans to expand forensic
beds, reduce Adult Mental Health beds, and open a crisis stabilization unit.
Central State Hospital in Milledgeville is the largest facility with over 800 beds.
Approximately 200 Forensic beds are divided between two buildings: Freeman, a
secured unit, and Binion, the only maximum security unit in the state. There are
approximately 100 adult mental health beds located in the Powell Building, and
approximately 30 child/adolescent beds in the Crittenden Building. The Craig
Center is a long term treatment center with nearly 200 medically compromised
patients, some receiving skilled nursing care, others receiving intermediate care.
These patients may have a psychiatric diagnosis, may have dementia, or may be
developmentally disabled, but their physical infirmities make medical/nursing
needs their priority. The remaining approximate 350 beds are for the
developmentally disabled and are divided between Allen Hall, Phoenix Center,
Pecan Manor and Piedmont Hall.
Northwest Regional Hospital in Rome serves three populations: Adult Mental
Health, Forensic and the developmentally disabled. AMH beds number slightly
less than 100 and are divided between two units. The Forensic population is on
one unit of approximately 55 beds, and the remaining four units hold just over
100 beds for the developmentally disabled.
Southwest Regional Hospital in Thomasville is primarily a facility for the
developmentally disabled, with over 150 beds for this population. Approximately
50 of these beds are for higher functioning patients and are being phased out as
placements become available in the community. Rosehaven treats those that
have severe medical challenges, and some beds are designated as SNF (skilled
nursing), while others are designated as an ICF (intermediate care facility).
SWRH has a limited Forensic unit with only 19 beds, and another unit with
approximately 50 beds for adult mental health. The census on these units is
consistently at capacity.
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SURVEY METHOD
Prior to the initial hospital visits, several planning meetings were held with the
Division to understand its needs, clarify the desired outcomes and define the
survey methods. In collaboration with the Division, a comprehensive evaluation
tool was designed that would be used by the team members to standardize the
method and guide them through each hospital visit. The tool focused on certain
aspects of patient care, particularly, assessments, the identification, treatment,
and follow-up of medical issues, seclusion and restraint, treatment plans, the
provision of care, quality improvement and patient safety management. Each
survey team member was assigned specific items to evaluate in clinical
documentation, through staff and leadership interview, and by review of other
hospital records.
To insure a broad view and to address the concerns of consumers, consumer
families, and advocacy groups, pre-audit meetings were also held with
representatives of NAMI and other consumer groups. Before each facility visit
and survey, team members were briefed and reminded of the global issues that
were identified by these groups. In addition, specific recommendations such as
speaking directly with patients and meeting with staff members away from
management were incorporated into the survey method.
Prior to each audit, the survey team worked closely with each facility to obtain
information and coordinate the schedule for the visit. Hospital staff members
were extremely cooperative and helpful in providing a comprehensive packet of
information, which included policy and procedures, chart forms and documents,
staffing patterns, organizational charts, job descriptions and other specific
information regarding hospital operations.
The audit schedule at each facility was generally consistent in nature, but was
customized to fit the unique structure, services and composition of each hospital.
Most facilities received a two-day audit; Central State in Milledgeville and East
Central in Augusta received three-day audits due to their larger size and
complexities. In general, the survey process included:
1. Pre-audit information review. The information provided by the hospital prior to
the audit was reviewed, organized, and copied for each team member.
2. A pre-audit team meeting. Team members discussed the pre-audit
information packet and reviewed the audit tool. Updates and Individual
surveyor assignments were also made at this time.
3. An opening day meeting. The survey team met with hospital clinical and
management team for introductions and general hospital overview.
4. Daily Survey agenda, which included:
A. Chart Review. Charts were reviewed on all units by at least two team
members. Comprehensive reviews were conducted as well as cursory
reviews related to certain issues or tracers.
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B. Staff Interviews. Staff interviewed included Nursing Executives and
Management, Physicians, line staff on units including Nurses and
Health Science Technicians, Safety Officer, Patient Advocate, Peer
Specialists, Human Resource Director, Pharmacist, UR Coordinator,
Risk Manager and Performance Improvement Coordinator. In
general, both front-line staff and management were supportive of the
survey and were eager to provide information and receive comments
and feedback.
C. Patient Interviews.
D. Further review of documents expanding to meeting minutes and
Quality Improvement Activities.
E. Treatment Team Attendance.
F. Unit visitation to observe the treatment environment, milieu, and
programming. The clinicians tried to spend as much time as
possible on the units, actually conducting their chart reviews in the
nursing station in order to observe staff-staff and staff-patient
interactions. The Admissions area, 23-hour observation unit and
the Treatment Mall were also visited.
5. At the conclusion of each day, a mid-survey summary was presented by the
survey team to Hospital Management to report initial findings, plan the next
day schedule and make mid-survey requests for additional information.
6. The survey team then met privately to review the day’s audit results, share
general impressions, and refocus individual assignments based upon
progress and findings of the day.
7. Wrap-up with Survey Team and Clinical/Management Team to review
findings and give immediate feedback of significant issues.
8. Compilation of findings of individual surveyors into summarized report.
9. Submission of written survey report. The survey report of individual facilities
submitted within 30 days of the visit served as an “Interim Report” or a
component of the final analysis and report on the entire system.
10. In some cases, an action plan addressing the individual hospital findings and
recommendations were submitted back to MCG Department of Psychiatry.
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SURVEY TEAM COMPOSITION
The MCG Department of Psychiatry policy and procedure team will be carefully
selected to provide a depth and variety of experience and knowledge specific to
this task. All members will be external to the system so that there will be no
conflict of interest enabling them to provide objective appraisals of policies and
procedures. The psychiatric physician on each hospital survey team was a
Medical Director of an out-of-state hospital or system with added qualifications
and experience pertinent to the specific population of their assigned hospital.
Each site was visited by a team consisting of one to two board-certified
psychiatrists with additional certifications in Forensic Psychiatry and/or Child
Psychiatry, another physician board-certified in Family Medicine with additional
qualifications in Psychiatry, geriatrics, and substance abuse, one to three
Registered Nurses, one of which was also a Qualified Mental Retardation
Professional (QMRP), and an Administrative Team Leader. The composition of
each team to review selected policies will be proportionate and appropriate to the
scope and focus of each policy.
Project Co-Director
Peter F. Buckley, MD
Peter F. Buckley, MD, is Professor and Chairman of the Department of
Psychiatry and Health Behavior at the Medical College of Georgia in Augusta.
An expert in the treatment of serious mental illness, Dr. Buckley provides clinical
care and conducts research on the treatment of schizophrenia. While previously
Vice Chair at Case Western Reserve University in Cleveland, Ohio, he served as
Medical Director for the adult state psychiatric services for Cleveland and Toledo.
During his tenure as Medical Director, this system was voted Best Hospital in
Ohio and received Joint Commission commendation with eleven Best Practices.
Dr. Buckley is on the board of several professional organizations, is a member of
the scientific Board of the National Alliance for the Mentally Ill, was a member of
Georgia’s recent gubernatorial task for mental health, and is listed in Best
Doctors of America. He is the recipient of several awards for his work, including
an Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill,
and the Psychiatrist of the Year award from the Georgia Psychiatric Physicians
Association. Dr. Buckley is also the recipient of the American Psychiatric
Association Administrative Psychiatric Award for this work on state-university
collaborations.
Project Co-Director and Team Administrative Leader
Nan Lewis, MPH
Ms. Nan Lewis is a Senior Mental Health Administrator with over fifteen years of
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leadership experience in public and private sectors of the mental health system.
Ms. Lewis was Administrative Director for the Department of Psychiatry and
Health Behavior at the Medical College of Georgia, transforming this service from
a failing program to the major inpatient/outpatient service in Augusta. Prior to
that, Ms. Lewis served as Chief Executive Officer at two private hospitals in North
and South Carolina, and served in several administrative positions for Charter
Behavioral Health System.
In North Carolina, Ms. Lewis worked with the state to establish the first private
inpatient unit for the developmentally disabled/mentally ill to divert admissions
from state institutions. Also in cooperation with the State of North Carolina, she
opened a residential treatment program for juvenile sex offenders to provide an
alternative to incarceration. Ms. Lewis is on the Board of the Augusta Chapter of
the National Alliance for the Mentally Ill. Prior to her mental health administrative
career, Ms. Lewis was a Laboratory Technologist, and also holds a degree in
Medical Technology.
Team Physician – Family Medicine:
Dean Harrell, MD
Dean Harrell, MD, is Assistant Professor in the Department of Medicine at the
Medical College of Georgia and is also an attending inpatient geriatric
psychiatrist in the Department of Psychiatry and Health Behavior. He also
provides expert consultation on physical co-morbidity among psychiatric
inpatients at MCG. Dr. Harrell is board-certified in Family Medicine, with added
qualifications in geriatrics. He is also trained and is board -eligible in Psychiatry.
In addition to extensive experience as a geriatric internist with a subspecialty
focus in psychiatry, Dr. Harrell has previously worked as a substance abuse
counselor. Dr. Harrell is a Fellow of the American Academy of Family Medicine.
Team Physician – Psychiatry:
George P. Parker, MD
George P. Parker, MD, is currently Associate Professor of Clinical Psychiatry and
Director of Forensic Psychiatry in the Department of Psychiatry at Indiana
University School of Medicine in Indianapolis, and Medical Director for the
Indiana Division of Mental Health and Addiction. Before joining the Indiana
University School of Medicine in Indianapolis, Dr. Parker was Assistant Professor
of Psychiatry at Case Western Reserve University School of Medicine in
Cleveland, Ohio, and Medical Director of Northcoast Behavioral Healthcare
Systems in Ohio, the state hospital system that serves all of northern Ohio via
three state psychiatric hospitals. He is a professional member of NAMI and is
active with NAMI-Indiana.
Dr. Parker is board-certified in General Psychiatry and Forensic Psychiatry. He
has received certification by the National Board of Medical Examiners as a
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Diplomate, and served as an examiner for the American Board of Psychiatry and
Neurology. Dr. Parker also received a certification in Mental Health Executive
Leadership from the Weatherhead School of Business Administration at Case
Western Reserve University
Team Physician – Psychiatry:
Marion Sherman, MD, DFAPA, MBA
Dr. Sherman is currently the Chief Clinical Officer of Twin Valley Behavioral
Healthcare/Columbus Campus, and is on the clinical faculty of Ohio State
University and Ohio University. Prior to her appointments in Ohio, she served as
Clinical Director of Child and Adolescent Services at the University of Utah
Neuropsychiatric Institute, and was on the clinical faculty of the University of Utah
Medical School in Salt Lake City.
Dr. Sherman is board-certified in general psychiatry, child/adolescent psychiatry,
and forensic psychiatry by the American Board of Psychiatry and Neurology.
She is a member of the American Psychiatric Association, NAMI and the Ohio
Psychiatric Association, where she currently serves as President. She has been
awarded the “Exemplary Psychiatrist of Ohio” by NAMI Ohio, and was featured in
the 2004 Joint Commission “Spotlight on Success.”
Team Physician – Psychiatry:
Douglas A. Smith, MD
Dr. Smith is currently the Medical Director of Northcoast Behavioral Healthcare in
Ohio, which includes three psychiatric hospitals offering inpatient adult and
forensic services and outpatient programs. He is also an associate professor at
the University of Toledo and Case Western Reserve University School of
Medicine. Dr. Smith is active at the Toledo Correctional Institute, where he
performs assessments and treats the mentally ill.
Dr. Smith is board-certified in General Psychiatry and Forensic Psychiatry. Dr.
Smith received a certification in Mental Health Executive Leadership from the
Weatherhead School of Business Administration at Case Western Reserve
University. He serves as a Medical Advisor to NAMI of greater Cleveland.
Team Nurse:
Patricia W. Coppett, RN, BS, MBA
Ms. Patricia Coppett is County Nurse Manager for Richmond County Health
Department in Augusta, Georgia. Ms. Coppett has over twenty years of
behavioral health care experience in the chronic, acute, forensic, residential and
community settings. She has worked with adults, children and adolescents as a
program manager and as a direct care provider. Ms. Coppett is a leading
community advocate and has served on the Board of the Augusta Chapter of the
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National Alliance for the Mentally Ill. Ms. Coppett is currently enrolled in the
Nurse Practitioner program at Georgia Southern University.
Team Nurse:
Janis Krauss, RN, BSN, MSQA
Ms. Krauss most recently served for six years as Clinical Decision Support
Analyst in Outcomes Management at the Medical College of Georgia. Prior to
that, she worked on the Behavioral Health Unit at University Hospital in Augusta
for approximately 10 years, in both management and staff positions. Her nursing
experience has also included medical/surgical care, including neurology,
intensive care and emergency. In addition to her Masters Degree in Quality
Assurance, Ms. Krauss received a Certificate in Health Care Evaluation in Health
Services Research offered by the Department of Medicine at MCG.
Team Nurse:
Alicia Wright, BSN
Ms. Wright is currently the Family Health Nurse Coordinator at the Richmond
County Health Department in Augusta, Georgia. Her 20-year nursing career
includes eight years in mental health and addictive disease caring for children
and adolescents, adults and geriatrics in an inpatient setting. She has served in
direct care and management roles, and has also performed as a healthcare
educator for both patients and nursing students.
Team Nurse:
Linda Wright, RN, BSN
Linda Wright has over thirty years experience in Mental Health with the majority
of it in state hospital settings. While most of her experience has been with the
developmentally disabled, Ms. Wright also has also worked with the forensic,
med-psych and geriatric populations. Ms. Wright is a QMRP, and has performed
in both direct care and management roles in state hospitals. Her management
duties included nursing and service line supervision for the dually diagnosed
mentally ill and developmentally disabled. For approximately five years, Ms.
Wright served as Quality Accreditation Manager for the Division of Mental Health
and Addiction in Indiana, where she was responsible for quality improvement,
accreditation and certification, and outcome measures. Currently, Ms. Wright
works for a pharmaceutical company as an expert clinical resource.
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REGIONAL HOSPITALS - INDIVIDUAL REPORTS
To better appreciate the scope and depth of the system report, both a brief
description of each facility and their individual audit reports are included below.
Some of the issues identified in the individual reports are significant and deserve
attention, yet they are not referenced in the final system report as they were not
found to be universal or consistent throughout the survey. It is worth comment
that during the course of the audit, as changes in practices resulting from survey
recommendations and accompanying corrective action plans were adopted, the
system communicated these changes in practices to other facilities. This was
evidenced by the shift in practices that was noted in subsequent hospitals as
they incorporated previous survey recommendations into their operations. It was
gratifying to see this beneficial effect occur from hospital to hospital. This was
also a reason why individual hospital reports were readily available quickly after
each hospital audit.
Also of note is that a relatively standardized format for reporting was used to
facilitate the comparison of the hospitals, enhance the communication of findings,
and facilitate the compilation of the final system report. Findings are divided by
general area, including chart organization and content, programming, physician
documentation,
medical
management,
quality
initiatives,
treatment
team/treatment planning, safety and environment of care, staffing, risk
management, utilization management, patient/family issues, seclusion and
restraint, safety and the environment of care.
Below is a synopsis of findings and recommendations from the audit of each
facility. The individual audit report for the facilities covers each of these aspects
in greater detail, including illustrative situations [this level of detail would be
extraneous and unnecessarily duplicative to be included for this report].
GRH - SAVANNAH
1. Chart Organization and Content–
Findings: Charts were inconsistent in order and content, making it difficult to
locate information and follow patient progress. This could contribute to other
noted problems below, such as follow-up of medical issues. Some forms
seemed excessive and repetitive, making information voluminous rather than
succinct and user friendly. Many required forms, such as consents for
medication or treatment, Advance Directives, and HIPAA forms, were missing or
unable to be located in some charts. Consent forms were improperly used, for
example, competence of patient signing forms either not addressed or patient
signing is clearly incompetent. Consent for medication forms allow multiple
medications on one sheet, allowing the possibility of meds to be added after
signature is obtained. Improper corrections of errors, such as white-out or blackout, or changes lacking date or initials, were also noted. Family involvement
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was never noted anywhere in chart, from admission, through treatment, to
discharge.
Recommendations:
a. Review standard chart forms, chart order and organization.
b. Educate staff on proper correction of errors in the medical record
c. Use one consent form per medication administered.
2. Programming –
Findings: Although Program schedules existed, it was not evident by observation
or by chart documentation that it was actually occurring. The Treatment Mall was
beneficial in dispersing the patient population and providing another environment
for them, but programming there appeared to be optional, and many patients
were seen outside socializing rather than participating in structured activities. A
new QI study tracking scheduled vs. actual activities had begun two weeks prior,
and although results were positive, further investigation showed that scheduled
activities may include recreational past times such as movies or bingo. Activity
therapists provide the major component of programming, and although
recreational activities are useful for patient management and can also be
beneficial to the patient, they should not replace therapeutic or educational
groups. Chart documentation typically tracked where patient was rather than
activity they were involved in and participation in groups such as AA were not
charted at all.
Recommendations:
a) Improve documentation to better reflect therapies, activities and level of
participation of patients, taking credit for services that are delivered.
b) Adjust audit currently in progress to separate therapeutic activities from
recreational activities to better reflect care being delivered to patients.
c) Maximize use of the Treatment Mall to address different population needs.
3. Physician Documentation –
Findings: Many physician notes were limited in length and detail, and generally
uninformative. Physicians, including the Clinical Director, verbalized difficulty in
meeting requirement of 5 notes/week/patient. It appeared that though the total
number of attending physicians for the hospital appeared reasonable, the
caseload of physicians on the acute unit seemed high, and may indeed
contribute to this problem. This impression is supported by variability between
units on quality of notes. Significant issues such as response to medication,
rationale for medication changes, justification for seclusion orders and multiple
medication use and patient progress on treatment goals, were sometimes absent
or inadequately addressed. On-call physicians sometimes saw patients without
documenting the visit. One physician routinely had PA students or medical
students documenting for him, signing off on their note.
17
Recommendations:
Suggest review and revision of statewide form for physician progress notes; as it
stands now, there is little room for discussion of treatment decisions or for
extended details of assessment. Need to investigate regulatory requirements
and appropriateness of third-party documentation for physicians. Require
documentation by on-call physicians. May also re-examine and evaluate case
loads of physicians on the acute unit to determine if documentation and
treatment expectations are reasonable.
4. Medical Management –
Findings: Lack of follow-up of medical issues consistently appeared in charts.
Most significant was the number of issues identified in just a sampling of charts,
and although some of these issues were inconsequential, others had the
potential to lead to serious medical complications. Included were such issues as
lack of follow-up of patient status or conditions identified on admission (i.e. head
injury, bandaged arm), results of lab and diagnostic tests (i.e. abnormal blood
sugars, LFTs, CPK, thyroid studies, and mammograms), new diagnoses made
without further work-up (i.e. dementia), positive reports on pain scales, and
previous medical conditions left unaddressed. The problem was not attributable
to merely oversight, as many conditions were originally documented or initialed
by the physician.
In addition to lack of medical follow-up, some established procedures (or lack
thereof) were not best practice. For example, there seemed to be no clear
established detoxification protocols, and risk of withdrawal/detoxification was not
documented or discussed in charts of patients with substance abuse issues.
Intramuscular (IM) PRNs are routinely written and administered without physician
assessment. This could be interpreted as a procedure allowing an agitated
patient to be “restrained” without physician notification. There did not seem to be
routine review by a pharmacist for polypharmacy, contraindications or food/drug
interactions. Polypharmacy did not appear to be widespread in charts reviewed,
but where it was used there was little to no justification to support the practice.
There is no place on the physician admission form for current medications on
admission, and often this information was missing or not located. Having it on
the physician admission form may also be a useful prompt for admission
medication orders.
Some practices were not consistent with established policy and procedure, for
example, UR policy requires extended stay administrative and clinical review.
Staff verbalized that it was happening in Treatment Team and in Administrative
Daily Briefings, but it is not well documented. And although current Seclusion
and Restraint (S&R) practice meets established guidelines, policy does not (staff
stated that policy is up for review and will be changed).
18
Recommendations:
Suggested methods include but may not be limited to:
a) Keep this a priority issue when addressing chart organization
recommendation (#5 below), as this may contribute to this problem.
b) Consider redistributing caseloads of physicians.
c) Examine role of primary care staff physician in coordinating patient care with
the attending psychiatrists, clearly define performance expectations,
responsibility as a member of the treatment team, and communication
methods for handling both referrals to and recommendations from.
d) Set up a check-and-balance system so that diagnostic test results are
followed up on.
e) Establish a QI study for continued monitoring and follow-up on action plan
results.
f) Use Treatment Teams to enhance communication and follow-up of patient
care issues.
g) Attempt to increase family communication and involvement in treatment to
obtain a clearer picture of patient history, condition, and response to
treatment.
h) Review and revise as appropriate policies dealing with S&R and the use
of PRN-IMs.
i) Develop policies on detoxification protocols and establish guidelines for the
identification
and management of risk of withdrawal.
j) Review and establish policies on pharmacist involvement in medication order
review.
k) Develop methods to insure obtaining a list of current medications at time of
admission with physician review.
5. Follow-through on Quality Initiatives –
Findings: The number of quality initiatives underway was impressive, with
committees such as P&T, Safety, Client Rights and HR conducting studies as
well as hospital-wide initiatives related to patient care. Data comparison with
other hospitals was also evident, with benchmarks and goals recorded and
tracked. Administrative support for these efforts was clear, with the Hospital
Administrator participating on many levels in the initiatives. Some initiatives
ended with data collection, however, and through further analysis, plans of
action, and/or recheck of areas of needed improvement or identified problems
were absent. Some responses and actions were able to be verbalized, but there
was not a paper trail recording progress. For example, surveyor noted from
medication error tracking that the predominance of errors was occurring on
second shift, but this trend appeared to be unobserved. Many results, including
client assaults, falls and injury rates, which did not meet benchmarks, had
actions documented in minutes as “deferred.”
Follow-through on significant
problems or issues such as abuse complaints or sentinel events was not evident
in quality documents.
19
Recommendations:
a) Ensure that minutes of meetings that address quality issues flow from month
to month, with action plan results recorded and addressed until closure.
b) Avoid “deferred” as an action plan.
c) Make sure that all data that is collected is analyzed, and not just recorded for
the sake of recording.
d) Remember that just as in chart documentation - what is not documented did
not happen – so take credit for what has happened by documenting in
meeting minutes and QI records.
6. Treatment Team – All treatment teams attended were organized, respectful
and relaxed, with attendance by physician, staff and patient. Unit 5 had a very
interactive treatment team. Unit 6’s treatment team was more physician driven,
with limited input by other staff, and chart seemed to be passed around for
signature with limited discussion. Orders and privileges were changed to reflect
current patient status.
7. Physical Environment –
Findings: GRH-S is challenged by being a smaller facility with a high census,
and therefore has a mix of diagnoses, acuity levels and patient populations in a
single milieu with limited space. The acute unit typically overflows to the long
term unit. Consistently, there are developmentally disabled and substance
abuse patients experiencing detoxification mixed with varying acuity levels of
Mental Health Patients, making it difficult to meet all the needs of a very diverse
population. Staff and physicians both expressed frustrations with both high
census and patients with mental retardation (MR) or substance abuse (SA) as
the primary diagnosis still being admitted. The physical environment was more
challenging on the acute unit than the longer stay units, which were brighter,
calmer and had better sightlines. With this consideration, the staff on the acute
unit is to be commended for maintaining order on a very busy day. The security
on the forensic unit was consistent and appropriate without being intrusive. With
over census being a consistent issue, cots are routinely used for sleeping,
creating both a privacy and comfort issue. A safety issue of removable
telephone cords of potentially dangerous length was noted on every unit.
Interviews with patients did not reveal any grievances.
Recommendations:
Remove telephone cords on patient units. Suggest replacing with short metal
cords (as found in typical public telephone booths) which are not removable.
8. Staffing –
Findings: All staff interviewed seemed to enjoy and be committed to their jobs.
There seemed to be good staff attitude and morale. On a record high census
day, line staff was not only managing very well on what could have been a very
chaotic unit, but also took time to respectfully greet and welcome us. This was
also evident on the unit in the interaction with patients and control of the milieu.
20
The impressive low utilization of Seclusion and Restraint also is a strong sign of
awareness, involvement and skill in managing a difficult environment. When
problems and “wish list” solutions were solicited from staff, most provided very
productive responses and reasonable expectations for change.
These
suggestions included enhanced training for Health Service Technicians,
improved programming on units, education on how to handle mentally retarded
patients and training on methods to prevent/address client-client and client-staff
assaults. Hospital Administration, management and staff and physicians were
receptive to our observations and input, and seemed appreciative of our visit and
comments. A sense of frustration was most evident from the medical staff,
however, in attaining goals and expectations set for them.
Nursing staffing seemed inconsistent, with what appeared to be extreme day-today swings in number of staff. Notably, weekend staffing appears to be
significantly lower than weekday. As with physicians, the total number of social
workers seemed adequate, but with perhaps a disproportionate workload on the
acute unit. This may impact functions such as discharge planning, therapeutic
programming, and family involvement with treatment, all identified as
opportunities for improvement. Role/use of psychologists was not evident in
chart documentation, observed programming or staff interviews.
Recommendations:
As with physicians, look at caseloads of Social Workers on Acute vs. the other
two units, which could positively impact discharge process (and consequently
readmission rates), family involvement in treatment and programming.
9. Training/Staff Development – The MANDT program is comprehensive and
effective as evidenced by the low number of Seclusions and Restraints. The
number of days spent in orientation for new employees allows for thorough
review and training in hospital procedures.
GRH - ATLANTA
1. Developmentally Disabled Units (DLC and SNF) –
Findings: Impressions from both the RN and physician team members on these
units were extremely favorable. The facilities were bright, appealing and very
clean. Patients were dressed and well cared for. Staff members expressed job
satisfaction, and were warm and caring in their delivery of care. Charts were well
organized, documentation was excellent and included several specialized
assessment tools. Medical problems appeared to be quickly addressed,
including follow-up of abnormal lab values.
Pharmacy completes a
comprehensive medication review.
The physician was commended as
wonderfully dedicated to her patients, an extremely challenging and difficult
population. Families were formally invited to participate by written invitation to
quarterly nursing assessment meetings. These two units did not seem to share
21
the problems or concerns of the rest of the facility, or at least they were not as
significant an issue, and are not included in most of the following notations.
2. Chart Organization and Content–
Findings: Charts of patients with longer length of stays (East and Forensic) were
routinely and completely purged prior to certain dates, and stored off unit in
separate records. This process seemed random and not dictated by defined
methods or policy. For example, some charts had all information prior to dates
as recent as March 2007 completely removed, and information critical to patient
care, such as the original history and physical examination, were no longer in the
record.
On the shorter term units, completed forms and/or documentation belonging in
the chart were often not found, and staff had difficulty locating these in loose
filing. In one case, a seclusion and restraint record was over a week old, but was
not in the chart.
The format of some of the preprinted forms contributed to excess paper in the
chart, containing good informational prompts, but spread out more than it needed
to be. On the Physician Psychiatric assessment, there is no “Formulation
Section” which is where the documentation should support the treatment.
Abbreviations were found in a physician order that nursing was unable to
interpret.
It was unclear whether staff was uninformed about approved
abbreviations, or if these were not on the hospital approved list.
Recommendations:
a) Review and/or revise policies related to purging current records to insure that
pertinent information remains on the active chart. This process should be
defined and completed by Medical Records staff.
b) Review loose filing responsibilities and practices, set timelines for inclusion of
records in charts. For seclusion and restraint records, review forms the
following day IN the record during treatment team to monitor compliance.
c) Review format of preprinted forms to consolidate and better present
information and reduce excess paper. Evaluate need for Formulation Section
on the Physician Psychiatric assessment.
d) Review hospital abbreviation lists, educate staff and physicians on approved
abbreviations, and enforce compliance.
3. Programming –
Findings: The activities building was visited by two survey team members, once
in the morning and once in the afternoon. The schedule was posted on the wall
and allowed for more than one activity to be occurring at any one time. A staff
member was questioned about designations on the chart which appeared to be
what discipline was leading each activity, but she was unable to interpret. In the
morning, the surveyor noted a group of patients being led outside to participate in
an activity, and though arriving in the middle of a scheduled group session,
22
another staff member appeared to be just getting started with another group of
patients seated at tables. In the afternoon, the second surveyor noted a few
patients playing basketball, but the majority of them were sitting around.
Unit program schedules were reviewed, and a selection of activities was provided
for most time slots throughout the day. In theory, this allows patients choice and
also provides activities for patients with different levels of functioning. In practice,
it appeared that patients elect the diversional activity more often than not.
Patient on the Forensic Unit complained about inconsistency in program
schedules, and that they changed frequently.
Substance abuse programming was noted on the West and Central Adult Unit
schedules, but the charts of patients with substance abuse listed as a diagnosis
lacked substance abuse groups or treatment documentation. This could be due
to patients electing not to attend, or due to poor documentation. Substance
abuse groups were not noted as being offered on the adolescent program
schedule.
Structured classroom time appeared not to be offered on the
Adolescent schedule, but rather optional “Independent Study” time, which may or
may not provide adequate supervision for students to stay current in school work
while hospitalized. It was not noted whether a teacher is employed by the
hospital to oversee or coordinate school work.
Activity Therapy does a good job with chart documentation of groups and
activities, with forms being both informative and efficient for therapist to
complete.
Recommendations:
a) Ensure that staff understands posted schedules, and that there is an
expectation that groups begin on time.
Evaluate the efficiency and
effectiveness of providing multiple groups at one time, allowing patients to opt
out for diversional activities rather than therapeutic. Chart documentation
should reflect groups attended.
b) Add substance abuse groups to the Adolescent Program schedule. Even if
patients do not have diagnoses of substance abuse, adolescents could
benefit from drug education and awareness.
c) Adolescents are greatly defined and affected by their school performance,
and educational interruption due to their hospitalization should be minimized
as much as possible. Education and school coordination should be a priority
during their treatment
4. Physician Documentation –
Findings: Physicians were not meeting the stated new requirement of 5 out of 7
days daily progress notes (note that Medical Staff Rules and Regulations state
two different standards). There was inconsistency in what type of progress note
was being used, sometimes the computerized version, sometimes handwritten.
23
The form does not allow adequate space for complex problems when used
manually, and therefore is often illegible. Many notes are also deficient in useful
information on patient status and progress.
Several forms requiring physician signature were found unsigned, including MD
verbal orders, seclusion orders, seclusion and restraint review forms and
involuntary commitment records.
Physical examinations were found to be late, scanty, or blank in 50% of the
charts reviewed by the psychiatric surveyor.
Polypharmacy or comorbid psychotropics, were not always justified in
documentation, nor were medication changes.
Recommendations:
a) Correct Medical Staff Rules and Regulations to be consistent in requirement
of frequency of documentation. Evaluate the number of physicians by
workload to increase numbers and improve performance. Impressions were
that an additional psychiatrist could be added to cover Adult Central and West
(½ FTE each), and if East is converted to a short term unit, another FTE
there. Another medical physician was indicated as well. Physicians state
they are seeing 30 patients in a 2 hour clinic for referrals for medical
conditions.
Adolescent may have adequate coverage, but when this
physician is out, pulling psychiatrists from other units creates shortages there
and disrupts continuity of care for the Adolescent Unit. Suggest some sort of
regular cross coverage for Adolescents with the above mentioned FTE
additions.
b) Additional FTEs should help to address issues of inadequate notes, deficient
documentation, and missing physician signatures, but also should set up a
system to monitor compliance.
c) Mandate use of computerized note, or provide an alternative form for
handwritten notes that allows adequate room for documentation.
d) Audit timeliness and quality of physical exams.
5. Consent Forms –
Findings: Several issues were noted having to do with consents. On the
Adolescent Unit, there is an apparent lack of understanding on legal issues
related to consents. There was conflicting or lack of information in the chart
regarding guardianship or custody, and thus the ability to give consent for a
minor. In addition, it was noted in an adolescent chart that the “patient lacked
capacity” to give consent, when the consent legally has to be obtained from
guardian and patient’s capacity is therefore irrelevant.
The practice of having multiple medications on one consent sheet was observed,
and it was evident that new medications were added since the original patient
24
signature was obtained. On two occasions, informed consents for medications
were not located.
Consent forms related to transfer from involuntary to voluntary status were
incomplete or absent.
Recommendations:
a) Conduct an in-service training on legal issues related to guardianship,
capacity and consents.
b) Revise consent forms for medication, requiring a patient/guardian signature
every time a new medication is added. Suggest listing an anticipated range
for medication identified on the consent, and therefore dosages can be
changed without additional consents being obtained, while at the same time,
patient is protected from significantly increasing dosages without additional
informed consent.
c) Monitor compliance for all consents
6. Seclusion and Restraint Documentation –
Findings:
In addition to the problems of absence of MD signatures on orders
and forms and completed forms not being filed in the chart already noted above,
multiple other problems were observed, making every Seclusion and Restraint
chart reviewed deficient in at least one area. Omissions included documentation
of routine observations such as circulation checks and vital signs, no bathroom
breaks or water offered, or no RN or MD assessment documented. One order
was written for a manual hold, seclusion, and restraint on the same order.
Policies such as notification of family and debriefings following patient release
were not followed or not documented. An “Administrative Restraint order” was
noted on one chart, although staff stated that these were no longer used.
Recommendations:
Seclusion and Restraint deserves attention as a designated QI project or regular
report of compliance to a quality team. This is always an area of scrutiny for
JCAHO, and also a high risk procedure deserving of pristine documentation and
records. Educate staff, monitor compliance, follow-through with consequences
for non-compliance. Use treatment team to monitor documentation and timely
inclusion in chart of completed form.
7. Medical Management –
Findings: Multiple charts were noted to have documentation of “unable to
assess,” or “refused exam,” and potential medical complications were left without
appropriate follow-up. Even without a “hands-on” exam, patients’ condition can
be somewhat assessed from a distance and documentation more helpful than
“unable to assess” recorded in chart.
25
There was also a notation of a patient refusing labs two times over a week ago,
but without further follow-up either changing the order or mandating compliance
with treatment.
The H&P form includes an area for listing medications, but the nursing
assessment does not provide for medication list recall. Charting of current
medications was inconsistent from record to record. A new JCAHO standard
requires a “medication reconciliation” list which is especially helpful for longer
lengths of stay. This insures that new medications added during the course of an
admission do not interact or are contraindicated with other medications patient
may be taking at home.
Pharmacy did review medication orders, but called or emailed physicians with
interactions or contraindications and notification did not always appear timely.
For example, a Friday night case was noted where the drug-drug interaction
notification was not found by the physician for 4 days, and another allergic
notification was not identified by the pharmacy until the next business day.
Inconsistency was noted in documentation of PPDs. The GRITS (Georgia
Registry for Immunization System) is not utilized for tracking immunizations for
Child/Adolescent or DD populations.
Risk factors for withdrawal, increased monitoring for detoxifying patients or
documentation of medical issues secondary to alcohol/polysubstance abuse
were noticeably absent on substance abuse patients.
There was some disconnect noted between the admissions unit and the
receiving treatment unit. PRN antipsychotic medications were ordered, but since
this was prior to the MAR creation, it was unclear to the unit physician and the
nurse whether any PRNs were actually given prior to the patient’s arrival on the
unit.
One chart lacked appropriate follow-up and adherence to a physician order for
constipation.
The historical incidents and consequential developed and
implemented action plans at this facility related to recording bowel movements
and reporting constipation make this particularly significant.
Recommendations:
a) In physical exam documentation, discontinue the practice of allowing “unable
to assess,” or “refused exam” as acceptable documentation for physical
exams and assessments. Mandate at least an observational note of patient
condition, with further documentation that the patient refused a more
comprehensive exam. Define follow-up options for patients with potential
medical complications, and timelines for repeat attempts to evaluate for all
patients.
26
b) Add a prompt for recording current medications to the nursing assessment.
Look into developing a policy for meeting the new JCAHO standard requiring
medication reconciliation.
c) Require Pharmacy to communicate directly with an on-site physician and to
indicate interactions or contraindications at the time of the dispensing of the
medication so that physician and nursing staff are aware before medications
are administered.
d) Standardize documentation of PPDs, and adopt GRITS (Georgia Registry for
Immunization System) for tracking immunizations for Child/Adolescent or DD
populations.
e) Develop policies to identify risk factors for withdrawal, and define monitors to
assess detoxifying patients. Include documentation of medical issues
secondary to alcohol/polysubstance abuse as part of the history and physical
exam.
8. Utilization Review –
Findings: The utilization management plan has been recently reviewed as it
contained 2007 goals, however, it is still in need of revision. The UR Director,
though relatively new in her position, could not explain some things contained in
the plan such as reference to Adult Mental Health Program Redesign 2002 and
Planning List Criteria, neither which are described in the policy but by which
patients’ stays are supposedly reviewed. “Questionable malingering” was listed
as an acceptable diagnosis. A list of 13 Focused Programs were included in the
Plan, although the UR Director stated these are outdated.
All of the mental health units, including East, are described as acute units,
however, patient condition and pathology did not seem to reflect this, and in fact,
in the opinion of the psychiatric physician surveyor, most of these patients could
be discharged. The observation of patients ready to be discharged was also
incongruent with the statistics that show an impressive trend line for decrease in
unauthorized days since the inception of APS review, and leads to the question
of what clinical criteria are used to authorize these patients for continued stay.
Two of the top five discharge diagnoses for 2005-06 as provided by the hospital
were Psychotic Disorder NOS and Depressive Disorder NOS, indicating a lack of
through diagnostic evaluation. This was also reflected in individual chart reviews,
such as where a patient carried an NOS diagnosis for over 2 years.
Recommendations:
a) Review and revise the utilization management plan and remove outdated or
inaccurate data.
b) Examine continued stay criteria of all patients on East Unit, and concentrate
efforts on discharging these patients. Overcrowding on Central and West
could then be addressed by transferring patients to these beds. This could
also alleviate physician workload.
27
c) Review use of NOS diagnoses an indicator of incomplete diagnostic
evaluations.
9. Quality Initiatives –
Findings: GRH-Atlanta has an impressive presentation of minutes and data
collection, including graphs tracking trends with segregation by unit. However,
again, there is general lack of follow-through. Most notably, the threshold for
action or concern seems to be set quite high, and there is no comparative data
from other GRHs, statewide standards, or other benchmarks from which
reasonable goals can be established or criteria for which action would be
required to be taken. For example, in a month where there were 23 staff injuries,
one of which caused an employee to lose consciousness and be transported to
the hospital by ambulance, the report stated there was “No single incident that
rose to the level of requiring a Performance Analysis,” and therefore no formal
performance improvement actions are taken. This statement is commonly seen.
Although medication errors committed by physicians were as high as 78 in one
month, no actions were indicated. The extremely low number of med errors
committed by nursing, sometimes none in one month, suggests that there may
be an underreporting problem.
The committee structure is confusing, with the Safety Committee being tasked
with patient care indicator monitoring and enforcement, but with little clinical
representation and no empowerment for follow-through. There is a system of
review, including generation of memo to a clinical manager, sometimes with
required response, sometimes only serving as information that a trend or a
significant issue is emerging or has arisen. The Safety Officer is competent and
invested in his duties. However, committee or organizational structure may have
reduced the impetus in ensuring compliance. The Provision of Care Committee,
which does have clinical representation, does not address issues of patient
incidents including assaults, falls, elopements, contraband and injuries.
As noted under medical management findings, there are continued problems with
monitoring and reacting to constipation in patients. This indicates a failed action
plan, and a disconnect between quality initiatives and quality implementation.
The plan, and monitored compliance with it, was excellent, but there was clear
evidence to the contrary.
Recommendations:
a) Set thresholds for action based on comparative data from other GRHs,
statewide standards, or other established benchmarks.
b) Examine barriers to reporting nursing medication errors to determine if current
numbers are accurate.
c) Revise committee structure to ensure that the proper disciplines and clinical
management are involved in quality initiatives and data review. Make sure
that there is appropriate follow-up, that people are empowered and also
receive support in effecting change and hold people accountable for
28
performance improvement in order to eliminate disconnects between planning
and implementation.
10. Treatment Team –
Findings: Treatment teams were attended on the Adolescent Unit, and Adult
West and Central Mental Health. Treatment Team schedules did not allow
attendance on the remaining units. In general, treatment teams were well
attended by all disciplines and patients. Central Unit’s team was well run,
interactive and group oriented. Medical issues were discussed, and the point
system utilized for patient management was addressed. Treatment Plans were
generally complete, but sometimes unclear as to assigned responsibilities as
names are used without indication of discipline they are representing.
Recommendations:
Indicate responsible discipline on Treatment Plans in addition to or in place of
individual names
11. Staffing, staff morale and attitude –
Findings: Probably the most significant issue identified in this survey was the
morale and attitude of staff, which was a consistent theme from line staff through
physicians and management. Some employees were reluctant, even fearful to
talk, while others stated that they had tried to express their concerns to
administration, but were unheard and felt unsupported. As a result, most staff
have either become apathetic or very frustrated. Frequently stated was lack of
teamwork and leadership. Though staff also articulated concern with staffing
levels and turnover, issues related to leadership and teamwork were much more
frequently and passionately expressed, and recognized by some as contributing
to the staffing problems.
The difference between GRH-Savannah and GRH-Atlanta was striking in this
regard. Though GRH-S had their share of opportunities for improvement, their
energy and attitude were markedly different, and this was felt by the survey team
almost immediately.
Another source of frustration seemed to be the mandated practice of sending
employee performance write-ups “downtown” before the problem can be
addressed with the employee, with a usual turn-around time of 2-3 weeks.
Managers felt that their hands were tied in expediently handling performance
issues. The difficulty in disciplining or firing long-term or “classified” employees
was also expressed, with some employees therefore acting entitled and unwilling
to respond to supervision.
Nowhere else is there better evidence of the effects of poor morale than in the
turnover and vacancy rates for Nursing. It is not surprising that the two short
term Adult Units and the Adolescent Units have the highest turnover rates, as
that is where morale is the lowest and problems are the highest. Agency and
29
PRN staff, who are typically paid a higher rate than regular staff, are responsible
for the majority of errors observed during the audit. The physicians feel not only
the effect of short nursing staff, but experience shortages themselves. A
significant source of discontent for the physicians is with mandated call, and then
they are paid less per hour than a PRN physician taking the same call.
Recommendations:
a) Take advantage of the recent Nursing Executive replacement and the
imminent Administrator change to create a perception of a new environment
and time for positive change for GRH-A. Solicit employee input, conduct
employee opinion surveys, and re-institute exit surveys. Make employees
feel they are part of the process of positive change. Pay particular attention
to the effects of the media exposure and continued scrutiny of the hospital on
the employees. It is very important to maintain open lines of communication
at this time, and while setting an expectation of improved performance, be
careful not to imply scapegoating or blame of individual employees.
b) Identify what is working on the SNF and DD units and try to replicate on other
units. Continue to move the acute units back to the Program Model to
encourage teamwork and cooperation between disciplines.
Remove
hesitancies to discipline classified employees if they are problematic.
Expedite the disciplinary process, if at all possible remove the delays involved
in Division review.
c) Concentrate heavily on retention of employees.
Encourage middle
management and supervisors to develop good relationships with their
subordinates. Have upper management model this behavior.
Address
some of the major issues, complaints, and contributors to burn-out such as
moving employees off their home units to cover other units, only to create
shortages from where they were pulled. Assign onsite shift supervisors to
relieve nurse managers of 24-7 call responsibilities.
Explore setting up
nurse mentoring program to allow new nurses to ease into shift
responsibilities. Consider self-scheduling. Instead of mandating shifts, MOD,
and OT, at least on a temporary basis, provide incentives to take call and
additional coverage (for physicians and nursing) by pay rates equal to what is
being paid to agency or PRN staff.
d) Resist the urge to hire just to fill positions, sacrificing quality for quantity. To
build momentum once change is evident and there is an upswing in morale,
encourage community exposure by employees becoming involved in mental
health, community, and professional organizations so that they can be the
ambassadors for the hospital and become recruitment leaders.
Once
positive change has taken place, become a training site for nursing schools
for their psychiatry rotations to encourage recruitment and create a learning
environment.
30
12. Patient and Family –
Findings: Several patients were interviewed and although most were generally
satisfied with their care, others were vocal about overcrowding (Adult MH and
Forensic), inconsistencies in patient schedules (Forensic), staff neither listening
or working actively on their discharge (East), staff preoccupied with their own
problems (all over), or fearful about being around other violent patients on their
unit. There was little evidence of family involvement in any chart, and Social
Work Services stated that they do very little family work.
Recommendations:
Family involvement in care will not only improve patient care, but will also help
mend community image. Social work should make family communication a
priority
13. Training/Staff Development –
Findings: There appeared to be a commitment to training, with a dedicated
training staff and building for this purpose. The orientation schedule appeared to
provide sufficient period of time for training. Competencies appeared to be in
order. However, staff commented that once orientation was complete, nursing
staff was immediately immersed in the unit without additional on-site training or
mentoring, and often felt overwhelmed. Some staff stated this contributed to
turnover. There was a comment that training was often used excessively and
inappropriately or inadequately to address employee performance problems,
without accountability or performance expectations set before or after training
was completed. Another staff indicated that they did not approve of the MANDT
program, although it has seemed to be successful in reducing Seclusion and
Restraint utilization.
Recommendations:
Establish a mentoring program as referenced above. Do not replace disciplinary
action with training when performance problems are not related to education
14. Safety/Environment of CareFindings: While on the Adolescent Unit, it was noted that patients are allowed
access to their rooms with door closures throughout the day; patient shoelaces of
lengths found on high top sneakers were observed in patient rooms, and patient
room doors are equipped with regular doorknobs, all contributing risk for patient
suicide.
There appears to be need of maintenance on many units, but especially the
adolescent unit, with loose floor moldings and other general repair issues noted.
On one of the exterior fenced yards for the adult males, it was noted that the
smaller mesh screen that discourages climbing of fence by making the holes too
small to fit fingers through was located at the bottom of the fence instead of the
top. Staff members indicated that this had been done because patients had
31
been unraveling ties at the bottom of the fence that attached the links to the
poles. This indicates lack of supervision in the outside area, as this would take
some time and concentrated effort on the part of the patient to unfasten these
ties.
Recommendations:
a) Look to replace doorknobs with slip knobs which will not support weight,
restrict shoelaces on unit, and restrict patients in rooms unsupervised.
b) Have Administrator do monthly walk-through inspections for general
maintenance issues.
c) Install small mesh to top of fence to discourage elopements.
d) Suggest instituting a smoke-free hospital environment
ECRH - AUGUSTA
1. Chart Organization and Content –
Findings: On the DD Units, because these house generally long term, medically
complex patients, records were very large. Perhaps in an attempt to make more
manageable, information was divided into two charts; a health chart and a
program chart. The charts were generally orderly, but sometimes as much as 23 years worth of documentation such as lab results, assessments, etc was still in
the active chart, and the Medical Record policy for retention was not consistently
followed. Surveyors were mixed in their report on ease of “tracing” problems
through the chart, but when tracing was possible, results were reported as
excellent.
There was some inconsistency noted on where in the chart staff documented
acute medical changes requiring physician notification, for example, there was a
patient whose vital signs were ordered to be checked twice a day for one week.
While this was being done, it was being documented in different places in the
chart by different staff, making it difficult to track changes or significant readings.
Charts were better organized and flowed somewhat better on the MH unit than
on the Forensic Unit. For example, the MH unit used the computerized version
of the Physician’s Progress note, which is awkward and provides insufficient
space for required documentation when used as a printed form with handwritten
notes. The Treatment Plan weekly update on the MH unit was also fully typed
and has more text than the Forensic unit. Due to longer length of stays, the
Forensic charts tended to be larger, and it was difficult to find current information.
On these long term charts, the initial evaluations, such as the H&P and initial
psychiatric evaluation, were often absent, though subsequent annual evaluations
were present, indicating an inconsistency in thinning chart practices.
There were various separate logs for 15-minute checks, I/O, S&R, etc., and there
was inconsistency as to when these would be placed in the patient chart, so
32
sometimes it was difficult to locate information. When S&R forms were found in
the chart, they were in the back of the physician order section, often in random
order rather than chronological order.
Recommendations:
a) Records of long-term patients could be made more manageable by purging
as defined by the medical record policy for retention.
b) Require or at least encourage the computerized version of the Physician
Progress note to provide adequate documentation of pertinent clinical
information.
c) When using separate log books for recording information, establish a policy
and monitor consistency for the inclusion of these in the permanent medical
record.
d) Establish a consistent guideline for where patient information is recorded in
the chart. This reference is specific to vital signs, crucial for medical
monitoring and management
2. Programming –
Findings: A wealth of programming seemed to exist for DD patients. Higher
functioning patients participate in work therapy and vocational training, classes in
independent living and social skills and functional academics. They are also
provided off-campus trips and outings.
A very impressive pseudo-store
mimicking an actual grocery store was set up this month to teach shopping skills,
including budgeting, money exchange and item selection. Patients were
observed participating in these activities.
Lower functioning patients receive occupational therapy such as personal care
and domestic training, music therapy and social skill training. Large, bright areas
for physical and movement therapy were observed, and patients were seen
participating in all activities.
Even patients unable to participate in structured programming were provided
music, televisions or other sensory stimulation. By far, most patients were seen
engaged in some kind of activity.
For Mental Health and Forensic patients, individualized activity schedules are
initiated by the RN, given to them at treatment team, and appear to be followed.
As in the other facilities, the treatment mall offered most of the programming.
Visits to the mall showed active groups and active participation from patients.
From logs documenting group activities, all disciplines seem to be involved in
providing programming, including psychology, nursing, social work and activity
therapy. On the AMH Unit, reports show that nursing provides more groups than
anyone, but they do not provide groups at all on Forensics.
33
An observed medication group consisted of interactive discussions on types of
psychotropic medications, side effects and interactions. Another observed group
for forensic patients educated them on court processes.
Most consumers would benefit from SA programming, particularly on the MH
units, where dual diagnosis is likely the rule and not the exception. One SA
group is offered on the unit, but often consumers were at the treatment mall.
Essentially no groups such as AA/NA/CA were noted.
Recommendations:
a) Enhance substance abuse programming, making it available to those clients
with identified dependency, abuse, use, or those at high risk for abuse, which
probably encompasses the large majority of consumers.
b) As noted, nursing provides many groups on the Mental Health Unit, actually
more than any other individual discipline. It was not determined if these were
provided by professional staff (RN, LPN) or Health Service Technician’s. If
Health Service Technician’s are providing the groups, the question of quality
of group and training/competencies are an issue. If professional staff is
providing these groups, a question of effective utilization of staff is raised.
Due to acute nursing shortages, nursing responsibilities that can only be
provided by nursing (assessments, medical monitoring, etc.) should not be
compromised for provision of groups when perhaps other properly trained
disciplines could provide these groups. Likewise, on forensics, nursing
provides no groups, so this population may not be receiving medication
education. This area deserves further evaluation. Treatment Mall vs. on-unit
programming needs to be evaluated for those clients who are not able to go
to the Mall, and therefore may not have access to therapy.
c) Some consumers in DD groups anticipated rewards following active
participation, but this was absent and their disappointment was evident. It
may be beneficial to consider a reward system for participation in group
activities.
3. Physician Documentation –
Findings: The annual assessments on DD patients were very well done,
thoroughly addressing numerous medical issues, but MD documentation was
otherwise sparse.
Interdisciplinary Periodic Health Reviews (PHRs) are
conducted quarterly, but documentation tended to be rather repetitive and brief.
One chart reviewed was missing a PHR.
Other physician documentation
consisted of short occasional progress notes, unless there was an active medical
issue which required more detail. Sometimes physician documentation was
contradictory.
Physician documentation for the psychiatric conditions of DD patients was
limited. This perhaps may be due to reliance on the psychiatric clinics operated
by the Augusta campus physicians who come over once a week. Notes for these
clinics were not observed in the chart. The surveyor may not have known where
34
to look or the clinic notes were filed separately. Psychiatric diagnoses were
lacking supporting documentation, and justification for psychotropic medications
used was often absent. This is a difficult population to treat because of the
ability to evaluate effectiveness of medications.
Identifying specific target
symptoms for reduction or elimination would be useful in the consideration of
initial use or adjustment of medication. This was not found to be present.
Only one telephone order was noted to be not dated and timed when signed.
Telephone orders are accepted, and “read-back” is documented. Some orders
on Camellia were noted not to always be in compliance with policy of MD signing
within 24 hours.
There was sufficient documentation to support patient diagnosis on MH charts,
but not as clear on forensics. The psychiatrist on the forensic unit was noted to
use generic notes, some of which changed very little from note to note, which
suggests minimal individualized assessment and documentation. Given the high
number of patients followed by this psychiatrist, it is likely that content was
sacrificed in the interests of efficiency.
A stamp was used to prompt physician signature of telephone orders with
inclusion of date and time, but this was not always completed.
Recommendations:
It is anticipated that most physician documentation issues would be addressed if
workload was decreased to reasonable levels with the addition of staff.
4. Seclusion and Restraint (S&R) –
Findings: Seclusion is not utilized for the DD population, and restraint use is
rare, as de-escalation techniques are employed and are successful. Protective
devices such as headgear and mitts to prevent self-injurious behavior were
observed with appropriate documentation and physician orders.
The low utilization of Seclusion and Restraint for the Mental Health and Forensic
population is commendable. The use of PRNs is relatively common, however,
and an intramuscular (IM) PRN is roughly equivalent to a hold/restraint episode.
IMs are also usually used when patients are put in restraints. Physician
documentation related to IMs is lacking, but nursing does document these well.
A surveyor arrived on the unit just as a patient was being processed out of
restraints.
The patient was in restraints less than one hour.
Chart
documentation was complete, and a debriefing was held. This was impressive.
Other charts reviewed did not show documentation deficiencies.
The use of the term “Administrative Restraints” was used by staff and also noted
in the chart, but not defined by policy. The policy is also unclear as to the role of
security/police in the application of restraints, which leads to training questions.
35
Recommendations:
a) Education on the reference to “Administrative Restraints” needs to occur, or
this term needs to be defined in policy.
b) If security and/or police are utilized in Seclusion/Restraint, their involvement
needs to be defined by policy and competency records should reflect training
appropriate to their level of involvement.
c) As in the other facilities, the practice of PRN IMs should be be examined and
addressed as a restraint, and policies developed to set guidelines.
5. Medical Management –
Findings: The medical needs of DD patients are generally extensive and
complex, and seem to be well addressed. The annual medical assessments are
extremely thorough. The best diagnostic criteria to assess care in a long term
facility for profoundly MR patients is skin integrity, and not one decubitus was
noted on review or reported by nursing staff, however, the Medical Director did
report one. In a population of 500 patients, this is a remarkable accomplishment
and reflects attentive care. Nursing reported that patients on the SNF are
routinely given two baths a day.
Some polypharmacy was noted, for example Seroquel and Haldol were
concurrently prescribed without much explanation. There was inconsistency in
monitoring medication levels, for example Haldol levels were being checked,
which is normally not done at all, yet a Depakote level was not checked for nine
months, when six month monitoring is standard practice. The pharmacist does
review medication orders for polypharmacy, contraindications, and interactions.
One chart was noted to have a patient going twelve days without a bowel
movement, however, staff seemed attentive with consistent documentation of
monitoring and interventions. The MD was notified after all else failed and a fleet
enema was administered on day twelve with results.
Dental care and oral hygiene was assessed as very good. Dental appointments
are at a minimum yearly, and identified problems have appropriate follow-up.
Substance use/abuse/chemical dependencies were noted as diagnoses in four
charts. Documentation regarding the diagnostic difference between the two,
which would be important in differentiating treatment modalities, was lacking.
There was no clearcut documentation regarding risk assessment for
dedetoxification/withdrawal, and no standardized withdrawal treatment
procedures (i.e. CIWA scales).
It was noted that nursing assessments were not completed on several patients
that had been admitted within the last 5-7 days. Nursing staff indicated that the
patient had refused or was non-compliant, but this was not documented in the
chart.
36
A few pain scales were either incomplete or were noted as elevated without pain
source or interventions documented. Refusal of medical monitoring was noted in
the chart, including a patient refusing blood draws for lithium levels and another
refusing blood pressure checks when they were on blood pressure medications.
Several patients had medical co-morbidities or positive diagnostic studies that
lacked appropriate follow-up. For example, two patients had documented
hepatitis without further liver studies or hepatitis profiles. One patient had six
fasting blood sugar results above 126, which is diagnostic of diabetes, without
treatment or follow-up. Another showed evidence of risk factors for Polycystic
Ovarian Disease without follow-up. An EKG was lacking on a patient with
documented irregular rhythm and gallop.
Medication management seemed more problematic on the Forensic Unit than on
Mental Health. Documentation of medication changes and/or dose changes on
the forensic unit was limited in scope if it was present at all. Consent forms for
medications were unclear and inconsistent regarding capacity to give consent.
The potential for drug – drug interactions with polypharmacy was noted.
Pharmacists did seem to work well and closely with the physicians and show
compliance with formulary. Medication errors and Adverse Drug Reactions are
so low that it suggests under-reporting.
Recommendations:
a) The medical management of substance abuse/chemically dependent
consumers has been a consistent issue in the review of facilities, and is one
to be addressed at ECRH. It is clear that there are educational, operational,
and policy development opportunities related to the assessment and
treatment of chemical dependency and substance abuse so prevalent in this
population.
b) Guidelines for interventions for patients who refuse assessment or medical
monitoring need to be established, and caregiver communication regarding
this is essential. At the very least, nurses need to be instructed to document
noncompliance, and record observations that do not require hands-on
interventions.
c) Education on the reporting of medication errors and adverse drug reactions
needs to be completed, as both appear to be underreported.
d) The quality and thoroughness of medical follow-up would probably best be
impacted by the expansion of the medical staff. Most co-morbidities or
abnormal diagnostic studies that lacked follow-up were not complex,
suggesting that it is not an educational issue, but rather a workload issue.
Likewise, lack of follow-up of positive scales again may be impacted by
staffing enhancements, but a check and balance system may also be
necessary so not to ignore this indicator.
37
e) Physicians should be encouraged to better document medication and/or
dosage changes, as well as the use of polypharmacy. For the DD client, it
would be helpful to target specific symptoms to be addressed by psychotropic
medications so that their effectiveness could be measured and documented
by team members.
6. Utilization Management –
Findings: Most patients who are long-term have very limited resources available
in the community that could meet their complex needs, making placement
difficult. There are a few “TIC,” Temporary and Immediate Care consumers that
come from personal care homes because of disruptive behavior or circumstance
changes, and these were observed to be reviewed for discharge planning
appropriately.
The admission wait list for Forensic is 20 days, with the evaluation wait time from
one to two months.
Resources or access to resources for patients who are discharged seem to be
poor, as many re-admissions seem to cite this as the reason for readmit.
Recommendations:
The Forensic system seems to be backlogged, which may be alleviated by the
addition of a Forensic Psychiatrist and additional community resources,
particularly supervised housing, to allow for more prompt discharge planning. It
was also noted that there were consumers Incompetent to Stand Trial that were
in the system for an excessive amount of time related to the offense with which
they were charged. This issue is large and complex, and may be under
investigation, but the incidence of this happening should not be overlooked
7. Treatment Team –
Findings: No treatment teams for DD were held at the time of the survey, but
treatment team documentation reflected interdisciplinary participation. One
chart’s team meeting lacked an MD signature, but staff reported that it is policy
that an MD attend and it was more likely that he/she had just neglected to sign.
Several treatment teams were attended on the Mental Health Unit by the
surveyors. The Forensic Unit treatment team was not held on the days of the
survey. All disciplines participated in treatment meetings, with the physicians
leading the team. Consumers were actively involved in the meetings, reviewing
their diagnosis, medications, activity schedules, medication compliance and
goals, and verbalizing understanding of their treatment plan.
Teams are only held once a week, so it is possible and not unusual for a
consumer to be discharged before the first team meeting.
38
Recommendations:
Treatment teams should be held more frequently than once weekly, as some
patients may not stay long enough to attend a team meeting, or their first team
may be on or near the day of discharge. This, again may be a staffing issue
alleviated by the addition of physician and professional staff.
8. Patient and Family –
Findings: Letters of invitation are sent to families approximately one month prior
to team conferences for long term patients, and family involvement was evident
in the chart for some clients. Appropriate notification was seen for reporting
adverse events and/or medical emergencies to patient’s families. Only one chart
was found to have inadequate charting regarding involvement of family in care.
Visiting hours are somewhat restrictive, allowing only late afternoon or evening
access.
Recommendations:
Consider expanding visitation hours. This would not only allow more contact for
the patient, but feedback from family, friends, and significant others can be
helpful in evaluating patient progress and changes.
9. Safety/Environment of CareFindings: A large and complex move was being conducted on the Gracewood
campus with the relocation of many patients from other buildings to a more
centrally located and recently renovated building. The move itself is noteworthy
as it was meant to increase efficiency of a scarce and valuable resource –
nursing personnel. Several safety issues were noted on the walk-through.
These were primarily related to the move. Though perhaps understandable
considering the scope of the job at hand, the staff was also cautioned that this
was their most vulnerable time for an incident, so safety precautions should be
intensified. Overall, the maintenance crew is to be commended for their attention
to safety, and their teamwork in striving to meet clinical staff’s needs. The
campus is also generally very well maintained, and the buildings and grounds
present a pleasant environment.
It is noteworthy that this population is smokeless, with an exception made for
three long-term stay consumers who are smokers, for which accommodations
have been made.
Hand sanitizer dispensers for infection control purposes were noted in all group
areas. Though effective for the control of contagious diseases, these can be an
eye irritant and safety hazard as they are accessible to consumers.
Several safety issues were noted on the walk-through of the Mental Health Units.
Suicide risks included plastic bags in patient areas, and unlocked doors to
closets and areas that clearly should have limited access. It was also noted that
39
the doorknobs to patient rooms seemed to be installed upside-down. The
exterior knob, installed correctly, would result in slippage if anything was tied to it.
The interior knob, installed in the opposite direction, would be able to easily hook
and hold weight and pose a suicide risk.
It was reported that suicide risk on the Forensic unit was usually not an issue,
and it was confirmed that there were no patients on suicide precautions at the
time of the survey. However, long removable phone cords in patient areas
(these were removed immediately), electrical cords, long shoelaces in athletic
shoes, and plastic bags being used in cans and stored in bulk in storage areas
were accessible and could pose suicide risks as well as weapons that could be
used in assaults. Other items that could potentially be used as weapons were
noted, such as a glass pot of hot coffee and housekeeping items such as brooms
and metal dustpans on sticks that were readily accessible in patient areas.
The restraint/seclusion room was obviously being used as a patient room, with a
chest filled with patient belongings and the bed made up for sleeping.
Justification by staff was that S&R was rarely used, and records confirm only 5
instances of non-ambulatory restraints in the last 6 months with the most recent
approximately one month earlier. When asked to show where the restraints were
stored, the staff knew where to look and they were accessible, but were at the
bottom of a drawer under other items. If restraint or seclusion were necessary in
an emergency situation, all these factors would inhibit expedited administration.
Further examination showed that the bed bolted to the floor in the seclusion room
was not an acceptable restraint bed, as there were no holes in the bed frame
where restraints could be securely attached to prohibit possible dangerous
movement by the patient.
Several interior doors were noted to open out into hallways or common areas.
These doors did not provide clear vision to warn of someone standing or passing
by on the other side, and so this could cause harm or injury. A surveyor actually
observed a staff member being hit by one of the doors. On some of the units,
red lines are drawn on the floor to delineate the hazardous area. This may be
helpful, but does not eliminate this hazard.
The Adult Mental Health Unit was separated into “pods.” One pod housed longer
term patients, another pod was for males, another for females, and another was
a mixed unit. Patient areas were small and felt somewhat closed in. The nurse’s
station is completely removed from the patient area, not allowing direct
observation from the work area. One nurse is often assigned two pods, and
must rotate between the two. This configuration and staff assignment leaves
Health Service Technicians routinely alone with the patients. “Panic buttons”
were installed in most areas of the unit to summon help from additional staff and
security in case of emergency. Lights on the wall indicated what area to respond
to.
40
It is noteworthy that there is a smoke-free policy for this population, which seems
to be working very well. Nicotine withdrawal is medically addressed with orders
and application of nicotine patches. Staff states that this is beneficial in milieu
and patient management and adherence to treatment schedules, not to mention
a health/wellness benefit for the consumer.
Recommendations:
a) Reverse the installation of the doorknobs and install as they were designed
so that they do not hold weight.
b) Safety issues related to suicide/assault should never be compromised
because of the absence of patients on those specific precautions, as patient
mix can change instantly. Be quicker to react to identified safety issues;
plastic bags as safety hazards were noted by both this survey and by Joint
Commission, but were still on the units when we exited.
c) Other identified risk items such as removable telephone cords, long
shoelaces, glass, poles and sticks should be removed from patient areas.
d) Although not much can be done to alleviate physical issues such as the
isolation of the nurse’s station away from the patients, this needs to be taken
into consideration in calculating staffing levels, both numbers of staff and
composition (Health Service Technician/Nursing).
e) Replace the bed being used for restraints with an acceptable restraint bed.
f) Although the facility is to be commended on their Seclusion/Restraint Training
and the low incidence of use, their ability to quickly implement the procedure
is hampered by a lack of “readiness” on the unit, as evidenced in using the
room as a patient room and inaccessibility of restraints.
10. Training/Staff Development –
Findings: Competency files on the unit for employees were reviewed and
appeared up to date and complete.
11. Staffing, staff morale and attitude –
Findings: Nursing staffing was reported to have been a significant issue for a
number of years, with a peak of 67% vacancy rate reached a few months ago.
Use of overtime, agency and hourly (PRN) is the norm. The remaining staff’s
tenures of 20, 25, 30 years provide a stable committed core and enable the
facility to continue to provide basic care despite the challenges that vacancies,
agency, and excessive overtime usage bring. Many of the deficiencies noted in
documentation, patient monitoring, assessment, treatment planning, and medical
management can be traced back to staffing issues, whether it be shortages or
sub-optimal performance due to lack of core staffing (agency/PRN).
Despite the staffing shortages, morale seemed positive and hopeful among line
staff, management, and physicians. Clinical disciplines seem to work together
well, despite the recent abandonment of the program model and the return to the
medical model due to reported failure and deficiencies noted on Medicare
surveys. This seems to be more due to leadership issues rather than the model
41
itself, which has since been addressed and corrected. Staff reported an
improvement in operations with recent organizational changes, and overall,
morale seemed to be on an upswing. Non-clinical and support departments also
seem to be on–board with the hospital team, and work well with the clinical staff.
Though understaffed themselves, physicians are generally satisfied, but are
frustrated with increasing workloads, high nursing staff turnover, and what they
consider inappropriate admissions to the short term mental health unit. The
Forensic unit is particularly understaffed, with only one psychiatrist for 60
patients. Though they do tend to be longer term patients, this is still too high a
patient-to-doctor ratio. As with RNs, the physicians have very long tenure; they
know each other and work together well, which contributes greatly to maintaining
patient care despite these deficiencies. The hospital plans to open a forensic
transitional program which means this ratio will soon worsen.
Physician staffing at the Gracewood Campus was adequate and stable, and
every member of this group has a long tenure. It will be very difficult to replace
such staff and management should begin to plan for recruitment well in advance
of any planned retirement or departure.
Staff consistently reported that they believe staffing, including both numbers and
competencies is the most significant issue facing the facility. Human Resources
is actively involved in recruitment activities, with a recent job fair being held.
They also conduct exit surveys and track termination data by several variables to
note and address turnover trends. It was noted that terminated employees (vs.
those that have resigned) are also given exit surveys, which may skew data
somewhat. HR provided data that showed ECRH lagged behind that of all other
state facilities for average hire salary for RNs, LPNs, and charge nurses, and a
proposal was being prepared to rectify that situation. Recent adjustments that
had been approved for new hires are creating disparities for nurses that have
been in the system for years, whose salaries now could possibly lag behind or be
nearly equivalent to new hires. Though unlikely to leave because of their vested
years of service, this could create morale problems among the very core group
which is holding this facility together. HR was also addressing this issue with a
proposal. Vacancy rates and turnover are discussed at Leadership Meetings in
the facility.
The effects of staff shortages were specifically noted by the surveyors during the
survey in two significant areas. At least on some units, mandatory narcotic drug
counts at change of shift are often done by only one RN or not done at all. This
may be due to staffing levels or may just be against policy. Although a problem
was not indicted with reconciliation, this practice would contribute to significant
issues if discrepancies arise.
42
Recommendations:
a) Staffing shortages for professional staff and physicians need to be addressed,
not only for the obvious immediate need, but also for the long-term stability of
the institution. The stable, experienced, tenured staff which is holding things
together despite shortages will be due for retirement in a short time, so
recruiting now to replace them with staff that will become seasoned and
experienced by that time is essential. Salary issues seem to be obvious, and
in a city with many other healthcare alternatives for professionals, this is even
more significant.
b) Recruitment is wasted effort without retention, and this needs to be
addressed as well. Fortunately, morale seems very good. In addressing
recruitment salaries, benefits, and bonuses, existing employee salaries
should not be overlooked.
c) Minimal requirements, experience, and training for Health Service
Technicians has become a consistent issue in the review of each facility, and
the quality of this staff which is tasked with the majority of patient contact
needs to be studied, evaluated, and addressed in all facilities.
d) Suggest eliminating giving exit surveys to terminated employees, if you don’t
want them working in your system, their opinions on how it should be run are
irrelevant. Their comments will tend to distort compiled data and dilute
usefulness of the survey results.
e) The Admissions/Observation Unit should be staffed with a nurse whenever a
patient is present.
f) Narcotic counts at change of shift should never be compromised or neglected
due to staffing shortages.
g) The medical staff needs to be supplemented, especially in Forensics.
12. Risk Management –
Findings: One DD patient was observed with bruising on his face. Upon
request, the surveyors were shown the chart describing the accident and
indicating medical follow-up, and the incident report form recorded with risk
management, detailing the account of the occurrence. Documentation was
excellent. However, the patient fell during a physical therapy session and the
incident may again indicate a lack of adequate staffing. Policies and practices for
follow-up of abuse reports or allegations were examined and found to be
thorough and appropriate. This included tracking of unsubstantiated claims to
note possible trends related to particular shifts or employees.
A clergy volunteer who provided individual and group spiritual services was
interviewed, and made some statements that would suggest that volunteers be
better trained as to appropriate boundaries with patients. He related discussions
with patients regarding abuse allegations that may complicate rather than help
resolve issues.
Both staff and physicians conveyed some discomfort with what they report as
overreaction to patient complaints. They feel that their ability to effectively treat
43
patients is sometimes compromised by a response to what they identify more as
patient pathology than valid complaints, and the result is often treatment
noncompliance. An example of this may be the nonperformance of exams and
tests due to patient refusal. This impression of over-reaction was not reinforced,
however, when talking to the patient advocate, risk manager, or human
resources.
Recommendations:
Provide training and oversight to volunteers, including clergy, to insure
appropriate boundaries in interactions with staff.
13. Quality Program –
Findings: The March Leadership Team Minutes described Function Groups that
will be formed for the analysis of clinical and human resource measures. These
groups are to look at key issues, allow detail analysis, encourage staff
participation and report back to leadership. As defined, this process is promising
to effectively address and or prevent problems before they arise by effectively
utilizing data. Results are not yet evident.
Five QI projects that were currently in place were also reviewed, including three
measures for MH and two for DD. These were very focused and limited in
scope, but worthwhile projects that were well done.
Because of the disproportionate number of long term DD clients at ECRH, any
aggregate and comparative QI data could be difficult to interpret or misleading.
It may be helpful to separate populations when collecting and examining
information.
Medical Staff Rules and Regulations still state that physician documentation is
weekly for the first 2 months, then monthly, which is not consistent with current
expectations.
Recommendations:
a) Continue with the Function Group plan to allow detailed analysis with staff
and leadership involvement.
b) Make allowances for the vast differences in ECRH patient populations when
aggregating data to make findings more relevant and useful.
c) Although the MH population is much smaller, those units seem more problem
prone and high risk, so the number and focus of quality initiatives should
reflect that.
44
WCRH – COLUMBUS
1. Chart Organization and Content –
Findings: Charts were generally in good order. Two charts reviewed contained
two abbreviations not on the approved list.
Recommendations:
Review acceptable abbreviations for the medical record with staff and/or make
reference material readily available.
2. Programming –
Findings: Programming occurs both in the Treatment Mall and on the unit. The
programs in the Treatment Mall are essentially available only for the residents of
the neighboring longer-term forensic unit. This mall offered a variety of programs
and appeared to adhere to its posted schedule.
Groups occurring on the units were not consistent with activity schedules that
were posted. Except for Unit 9, schedules did not indicate what staff was
responsible for providing a group, so when one was not occurring as scheduled,
it was difficult to determine who to contact. A group on Patient Rights that was
not occurring as scheduled was later determined to be the responsibility of the
patient advocate. She stated that she was in treatment team, which extended
beyond its usual time.
Some type of group note was consistently seen in the charts, however it was not
clear how many hours a day each patient was in active treatment. On each unit,
surveyors noted that at least 5-6 patients were in their rooms, in their beds, or
sitting unoccupied on the unit throughout the day. This was sometimes observed
during on-unit activities or while other patients were outside.
Substance abuse groups are offered three times a week, with one AA/NA/CA
group offered per week in the Treatment Mall. Participation in these groups was
not always noted in chart, so it was not clear if they were occurring, if patients
were participating, or perhaps participation was just not documented.
Facility reports of compliance with active treatment (scheduled vs. completed
groups) showed that many groups were not provided in the two weeks reported.
The Forensic Unit showed a much better compliance, while Unit 10 and 2, the
acute units, reported as low as 28% completed in a one week period.
Recommendations:
With stabilization of staffing levels, provision of groups should improve to
acceptable levels on all units. The hospital needs to increase number/type of
substance abuse programming and ensure that staff who lead groups are trained
and experienced in both the topic of the group and in group dynamics. The
medical record should reflect the type, number, and level of patient involvement
45
in groups. Unless medically indicated, patients should not be allowed to remain
in bed all day. Inclusion of the discipline or the name of the person providing
groups on the schedule would assist supervisors in holding people accountable
and adherence to group schedule.
3. Physician Documentation –
Findings: Documentation by psychiatrists consisted of infrequent notes with
limited content. Patients showed multiple medication changes, including type
and dosage, within a few days with little MD documentation.
Nursing
documentation was generally good enough for the surveyor to ascertain the
reason for the initial orders and for subsequent changes of medication. For
example, several patients on two antipsychotics had consistently inadequate
documentation by a physician as to the clinical reason for this practice, however
nursing notes provided enough information to infer the reason for the use of the
two medications. IM meds were also frequently ordered without justification or
rationalization documented.
MD signatures on verbal and telephone orders were often cosigned without the
date or time of the co-signature. Verbal orders, which are different than
telephone orders, are routine and accepted in non-emergency situations. There
is no notation of nursing documentation of read-back on the order sheet, but
nursing staff did state that it is their practice to do so.
Recommendations:
Physician documentation should improve proportionately with additional medical
staff. The practice of verbal orders (that are not by telephone) should be
discontinued except in true emergencies. Nurses are required to perform readback, and this needs to be documented. Changes in medications and/or
treatment regimens need to be better documented by physician.
4. Seclusion and Restraint –
Findings: Utilization of seclusion and restraint is very low, and many S/R rooms
are in fact converted to closets or storage. When questioned where restraints
were kept, staff often did not know or took some time to look for and find the
restraints.
The staff used the terminology of “administrative restraints,” but this is not
defined in policy. Justification for S/R should only be because of threat to self
and/or others. On some charts, this justification was not clearly stated on the
orders.
The practice of ordering manual hold/seclusion and manual hold/restraint was
noted, implying a choice delegated by the physician. The use of both terms on
one order is not necessary when the manual hold order is only for the purpose of
the “hold” that may occur in the process of secluding or restraining a patient.
46
Recommendations:
Either include definition of “administrative restraints” in policy, or educate staff to
discontinue reference to this intervention. Evaluate the ordering practice of
manual hold/seclusion and manual hold/restraint orders. The use of both terms
on one order implies a choice delegated to someone other than a LIP. Step up
MANDT training to complete and maintain 100% compliance.
5. Medical Management –
Findings: Generally, patients get prompt physical assessments on admission
and are adequately followed up on. Consults are ordered and promptly
performed. The documentation for these, however, as indicated above in section
2, is very scant.
Patients are allowed to refuse physical exams and diagnostic tests without
follow-up or subsequent requests or attempts to do the exam or test. Medical
staff attributed this to the workload of the internist, but the treatment team also
failed to monitor and follow-up on the refusals. One patient was admitted on 5/14
without having an H&P completed for nearly one month until 6/10 due to patient
refusal. Several patients were noted to refuse their annual H&P with no followup. Some patients also refused laboratory monitoring of the drug levels of the
medications they were being treated with.
Most changes of patient condition show appropriate physician interventions, and
MD signatures indicate review of labs and consults. One chart, however, did
indicate an obese patient with history of HTN who did not have a nutritional
assessment or referral.
Because of staffing shortages in pharmacy, concurrent reviews of medication
regimens no longer occur, but they are present on some older charts.
EKGs were not found on most patients who were on two antipsychotics. The
chance of developing arrhythmias is significantly increased when on two
antipsychotics, and therefore EKGs may be indicated in some circumstances.
Polypharmacy in the use of antipsychotics was frequently noted. One patient was
on three antipsychotics without reduction of psychotic symptoms. Pharmacy
reported that use of two or more antipsychotics was very common.
There seemed to be a reluctance to prescribe clozapine.
Diabetic patients lacked appropriate management, for example, all diabetic
patients should be placed on an ACE inhibitor or ARB2s for renal protection,
whether or not they are hypertensive. Urinalysis for proteins to gauge renal
pathology should also be routinely done.
47
In addition to the detailed chart reviews assigned to each survey team member,
20 random charts were scanned for substance abuse/dependence issues.
Although approximately 75% had this listed as a diagnosis, establishing this as a
prevalent problem, this medical condition is poorly addressed. For example,
there was no documentation noted that differentiated drug dependence vs. abuse
vs. use, which would dictate appropriate treatment modalities. Furthermore,
there was no documentation of risk assessments for withdrawal symptoms, or
evidence of withdrawal scales (i.e. CIWA) to objectively determine severity of
withdrawal for medical intervention. No documentation was noted on medical
problems commonly associated with substance use/abuse/dependence. Staff
physicians stated that any patients with “serious” withdrawal symptoms are
transferred out.
The present detoxification regimen uses Librium, which has a very long half-life
and thus can be detrimental to patients with liver disease. Librium has generally
been replaced in detoxification protocols with Ativan, which is similar but safer
drug with a much shorter half life, and thus can be used with patient with liver
disease.
Recommendations:
a) Policies should be developed and expectations set to define procedures for
when patients refuse assessments, diagnostic, or therapeutic testing, with a
minimum of expected follow-up when this occurs. The Treatment team
should monitor non-compliance and plan interventions.
b) Procedures for the medical management and treatment planning for
substance abusing/chemically dependent/substance using patients need to
be better defined. Librium should be replaced with Ativan as the drug of
choice for the detoxification regimen.
c) Education or review of best practices in the use of polypharmacy, the
prescription of clozapine, the monitoring of diabetics, obesity, and patients on
antipsychotics is recommended.
6. Utilization Management –
Findings: The UR Manager also performs as the Medical Record Director. UR
meetings and reports only occur quarterly rather than monthly as defined in the
UR plan because of staffing. Reports show that there were no inappropriate
admissions between October and February, which is incongruent with the need
to open a 24 hour observation unit and a crisis stabilization unit. This calls to
question the validity of these data. The need to create these two services, which
are normally outpatient services delivered by a community provider, reflects a
deficiency in the total mental health delivery system, and creates a burden on a
facility that is already struggling with providing inpatient services. Although
hospital leadership again is showing responsiveness to patient need and overall
system management, establishment of these new services with associated
training, policy and procedure development including admission criteria and level
48
of care differentiation, and physical move and renovations, especially with the
aggressive timelines set, creates more stress on a system that is struggling to
provide current services.
Legal status of some forensic patients was expired, and evaluations were
overdue. This clogs the system and contributes to the need to expand the
number of forensic beds.
Recommendations:
Ensure that defined criteria are established for the existing and new levels of
care (acute IP, 23 hour observations, and Crisis Unit) so that accurate, effective
and useful UR data can be collected and utilized
7. Quality Initiatives –
Findings:
Monitoring of important measures are in place, including readmissions, seclusion and restraint, medication errors, pain assessments, falls,
elopements, and client injuries. Trending and relational factors are considered,
for example re-admissions as related to length of stay (LOS), diagnosis, referral
source, and discharge disposition were studied. Reporting to appropriate
committees is occurring. Some indicators that are monitored by different
committees may create some redundancies, for example, client injuries are
monitored by a Risk Management subcommittee while staff injuries are tracked
by Human Resources. These are related and may be impacted by the same
variables, and probably should be tracked and monitored together with joint
action plans.
8. Treatment Plan/Team –
Findings: Treatment plans were very comprehensive and multidisciplinary. One
chart had an initial physician order for substance abuse treatment that did not
follow through to the treatment plan. Treatment teams are held daily and are
well run.
9. Patient RightsFindings: Patients sign consents for medication by drug class rather than by
specific medication. Medications within classes can differ considerably in risks,
side effects, benefits, and outcomes, and medication education could not
possibly be given for every drug within that class. These consents therefore,
cannot be considered “informed.”
Consent for clozapine, a complex drug, was completely lacking on one chart.
Patient’s capacity to give consent changed quickly in some cases, without
supporting documentation.
49
Forced medication procedures were unclear, especially for Forensic patients.
Orders were noted that stated “If patient refuses medication, may hold to
administer.”
Recommendations:
a) Immediately discontinue obtaining consents by drug class. Consents need to
be medication specific, with thorough drug education completed so that it
qualifies as informed consent.
b) Procedures for “forced medications” need to be defined, and changes in
patient capacity to give consent should be very well documented and
supported.
10. Staffing and staff morale –
Findings: By far, the most significant issues facing this facility relate to staffing.
Staff vacancies and shortages are evident in every level of the institution, and
include Physicians, Pharmacists, Psychologists, the Facility Administrator,
Nursing, Health Service Technicians (Health Service Technicians), and
transcriptionists, thus the delivery of care is affected on many levels. Some
positions have been vacant for over a year. Once again, as experienced in
Augusta, the ability to provide patient care can be attributed to a small core of
long-tenured staff that are experienced and committed. Their morale seems to
remain positive and hopeful, despite the significant challenges of running the
facility with vacant positions, agency and PRN staff. Many employees seem to
wear “more than one hat,” performing in interim or acting positions, or performing
more than one job due to vacancies.
Leadership stated that the beginnings of their staffing problems began with an
announced closure of the facility several years ago, which was reversed, but then
implied again at a later date. This created a sense of job insecuritywhich
resulted in many good employees leaving and contributed to the difficulty in
replacing them. Recruitment and retention have still not recovered from these
announcements, but then are even further impacted by the salary issues facing
this hospital, and all of the other hospitals in the system.
The facility was currently very active in addressing the staffing situation. Agency
and PRN staff were used as needed on the units and locum tenens physicians
supplemented medical staff coverage. The facility was prepared to go on
diversion the day of the survey to limit admissions after a busy weekend, but they
were able to postpone this due to the number of discharges by the end of the
day. An intense hiring effort was in progress with an abbreviated orientation
scheduled for the new employees to quicken the elimination of vacancies on the
units. Forty new hires had been made in the last month, with 34 of these being
direct care staff. These efforts reflect responsive leadership to address an
immediate crisis situation, but longer term issues of chronic vacancies and
turnover remain. Most of these efforts are short term, and the use of agency,
locums, and abbreviated training schedules only perpetuate problems as it
50
creates a sub-optimal work atmosphere and delivery of care. It was noted that
approximately 1/3 of these new hires were for Unit 10, the most acute, active,
and volatile unit.
The day of the survey, leadership reported that the hospital was fully staffed on
all units according to census and acuity levels that day. Surveyors noted
situations where despite having adequate numbers, at times staff-patient ratios
were still operationally stretched. For example, on one “pod,” there were 5 staff
assigned to approximately 15 patients - 2 RNs and 3 Health Service Technicians,
a very adequate ratio. However, when visiting the unit, one nurse and one
Health Service Technician were off the unit, and the other RN was behind closed
doors in the medication room. One of the remaining Health Service Technicians
was assigned a 1:1, which left the other Health Service Technician responsible
for monitoring and supervising all of the remaining consumers (14), some which
were on line-of-sight and/or other precautions.
On unit 10, two RNs were assigned to cover the entire unit for day shift. One
gave medications and the other did everything else. The same staffing occurred
on second shift. At change of shift, the first shift nurses handed off a number of
tasks that she had not been able to finish during their shift. This staffing is
insufficient, given the workload of this acute unit, without even considering
precaution levels or the number of daily admissions or discharges.
Physician shortages are reflected in the quality and quantity of chart
documentation. There is one psychiatrist assigned to cover 40 Forensic patients,
plus the Child/Adolescent crisis unit, and several acute patients on Unit 10.
During the survey, this physician was not responsible for these acute patients
only because a semi-retired physician had agreed to extend his usual duties in
order to cover these patients. This is clearly excessive. Unit 7, with longer term
AMH and Forensic patients, has one part time psychiatrist. This too is
inadequate. Unit 10, with 40+ acute beds is currently being covered with one
locum tenens, and was supplemented the week of the survey with the semiretired psychiatrist mentioned above. Unit 2, with 2 psychiatrists, was the most
stable of the acute units, but was still understaffed for an acute population. A
generally accepted ratio for acute units is 1 physician per 15 patients. The
delinquency rate for discharge summaries is at 43%, although some of this is
attributable to transcriptionist shortages.
Psychology is also understaffed, and is reflected in a back log of community
court evaluations and hospital reports.
Pharmacy is understaffed, and has been for quite some time. Workload has
been accomplished only through the use of contracts and agency pharmacists.
Consults and concurrent reviews are not occurring at an optimal level.
51
Employees at all levels consistently report that recruitment, retention, and staffing
issues are the most pressing problems for the facility. RN vacancy rates are as
high a 40%, and turnover for Health Service Technician’s from December to April
was over 100% (32 hired, 34 lost). Other issues expressed by line staff and
middle management as problematic were shift to shift communication, lack of
substance abuse treatment, and management of smoking privileges.
Recommendations:
Continue human resource staffing efforts by first eliminating the perception of
facility closure. This should include but not be limited to open communication
both internally and externally, filling key management positions, and
improvement of the appearance of the facility. Continue aggressive recruitment
activities, proceeding cautiously with the knowledge of the exposure and risks
these very efforts can temporarily create by flooding the workforce with new,
inexperienced and untrained employees. In recognition of the value the longterm employee brings to the facility, begin plans now for their replacement as
they retire and exit the system, which will significantly impact the operations and
stability of the institution. Begin efforts in retention to eliminate the 100%
turnover in some job classes, or else the increased hiring efforts will only result in
increased turnover. Ensure that abbreviated training is a temporary measure
only, and that those who attended the condensed orientation eventually complete
the entire training schedule. Examine salaries for all positions to remain
competitive. Supplement medical staff to attain reasonable workloads and
patient ratios.
11. Training/Staff Development –
Findings: The facilities records show that MANDT training is only 43% complete,
significantly lagging behind other facilities that have been surveyed.
Because of multiple vacancies, staff is pulled to work units that they are not
familiar with in order to meet minimum coverage. While visiting the units,
surveyors questioned Health Service Technicians and nurses about unit specific
issues, and found them uninformed about safety issues such as location of
restraints and panic buttons. Some staff questioned also could not interpret
abbreviations (HTN and DM) on the precaution sheets, therefore did not appear
to fully understand the exact risks for which they were monitoring patients.
Patient schedules on Unit 9 indicate that Health Service Technicians provide
groups such as the Community Meeting and Adaptive Living Skills groups. It
was not evident where or how they receive training on how to run groups or the
content of their group.
Recommendations:
a) Complete MANDT training as soon as possible for all direct care staff.
52
b) Include training or resources on group dynamics and specific group topics to
all employees providing groups, especially Health Service Technicians who
are likely to have no background or training in these skills.
c) If staff members are to provide cross-coverage on units other than their own,
basic safety training on alternate units should be provided. Any staff
providing monitoring of patients should be made knowledgeable of
abbreviations used to indicate risks/precautions.
12. Safety/Environment of CareFindings: Grounds appeared unkempt and overgrown, buildings were in need of
maintenance and repair, and patient furniture was worn and damaged. This is
significant as it perpetuates the impression that the facility is closing, which is
reported to be a continuing factor in recruitment and retention of staff.
The patient units created a difficult environment for patient observation and
management. Angles, alcoves, hallways, and corners allow patients to be out of
line of sight.
While the other units had closet doors removed in all patient rooms, Unit 2 did
not. On this unit, shoelaces, belts, and cords were also present. These together
create a suicide risk. Bathrooms also had grab bars attached to walls.
Also on the admission unit is an enclosed patio area on the interior of the building
that is unlocked and designated as a smoking area. The entire flooring of this
area is a low wood deck, which is not in good repair and could present a fire
hazard from cigarettes.
Recommendations:
a) Step up maintenance/repair of the facility buildings and grounds to eliminate
perception that the facility is closing.
b) Evaluate the potential safety hazard of the wood deck smoking area. Also
evaluate suicide risks on the only unit where closet doors have not been
removed and patients are allowed belts, shoelaces, and cords. Risks
associated with bathroom grab bars can be eliminated by installing current
bars at an angle that extends to close to floor level, or by purchasing new
bars with continuous connection with the wall the entire length of the bar so
not to allow tying or slipping something between the bar and the wall.
c) The physical environment as related to difficulties in patient observation may
be hard to correct, however, risks can be minimized by the positioning of
observing staff and moving patient telephones out of alcoves.
In the
admission area, when patients have not been assessed or evaluated for risks,
they should not be left in an unobservable area, and their access to potential
hazards needs to be limited.
53
13. Risk Management –
Findings: Quality studies done by the hospital showed non-compliance with reassessment of suicidal risk for continued stay or before discharge. Review of
charts supported a significant weakness in this area. One chart’s H&P indicated
suicidal ideation with plan, but the patient was not put on suicide precautions,
only line-of-sight observation. The treatment plan also did not reference any
intervention for suicide risk. Another chart on a patient preparing for discharge
had a risk assessment completed, but did not address the suicidal history of the
patient. This is a vulnerable area for the facility when coupled with other risk
factors.
As requested, a specific focus on issues related to patient and staff assaults was
conducted on this survey. Once again, leadership is commendably active in
addressing the problem of patient assaults in a crisis management mode. Daily
morning meetings report potential hot spots and review census levels and
staffing needs for urgent actions. Human Resource’s aggressive hiring and
orientation schedules is addressing immediate staffing shortages. On a larger
scale, creation of the 24-hour observation units and crisis stabilization units are
meant to address census levels and appropriate levels of care to better manage
and treat patients. Based on the current situation, these are appropriate
management moves, but also will stress the system further. Adding a large
number of new, minimally trained and oriented employees to the system carries
its own risks, including increased chance of turnover and increased statistical
odds of untoward events. The creation of new services, as mentioned earlier,
presents additional challenges to an already stressed system.
Client injury rate is also a performance improvement project. It has been
monitored and trended. Action plans included closer monitoring of patients,
requesting medical reviews by physician, and clients receiving anger
management and coping skills training. No “root cause” has been pinpointed.
The following issues related to assaults were identified during the survey
process, with some deserving further analysis and investigation.
a) There is a correlation between census level and patient injury rate.
The following chart visually represents how, when census levels reach
above 5000 DACE a month, the rate of client injuries proportionately
increase. Although this clearly represents that patients are at greater
risk of injury when census levels rise, this fact by itself is not
conclusive, as other variables related to increased census should be
examined.
For example, is staffing appropriately adjusted for
increased census, do groups still occur as scheduled with increased
activity associated with increased census, do treatment teams and
clinical oversight by the physician occur at the same frequency when
census rises, or does simple overcrowding on units contribute to
volatility leading to client injuries?
54
Client Injury Rate as Compared to Census
800
6.00
600
5.00
400
4.00
200
3.00
0
2.00
-200
JUL
AUG
SEPT
OCT
NOV
DEC
JAN
FEB
MAR
APR
1.00
0.00
-400
Monthly Variance from 5000 Patient Days
Rate of client injuries/1000 patient days
b) There is an unlikely correlation between number of seclusion and
restraint episodes and client assaults. Although the low utilization of
S/R is commendable, appropriate use would be a more acceptable
outcome in the management of volatile patients than patient and staff
injuries and assaults. The reason for not using S/R for de-escalation
and management of aggressive behavior should be explored - is it due
to lack of training (MANDT training is only 43% complete), an
inaccessibility of S/R rooms and equipment, or a reluctance to follow
and perform the extensive policies and procedures related to S/R,
including the paperwork, physician and family notification, patient
observation, and debriefings which are staff/time consuming?
c) Since MANDT training includes verbal de-escalation techniques and
crisis intervention to prevent S/R, the delinquent training schedule may
be contributing to uncontrolled situations resulting in patient/staff
injuries.
d) Vacancies, turnover, and agency utilization contribute to instability and
chaos on the units, as evidenced by the milieu experienced by the
surveyors on Unit 10 vs. Unit 2. Although both are acute units, Unit 10
experiences incidents greater in number and severity. This correlates
with the lack of physician leadership due to excessive workload (1 fulltime psychiatrist for 40 acute beds), high Health Service Technician
turnover and RN workloads on this unit.
e) Group activities not only are a component of treatment, but are also
conducive to patient and milieu management. Group activities were
both observed and reported by facility to not always be occurring,
55
especially on the acute units. This can contribute to patient boredom
and volatility.
f) Medication management, or lack thereof, was not noted to be an issue
contributing to patient assaults; however, high physician workload
could possibly be linked to inability to quickly address patient needs
without thoughtful and thorough assessment. This is evidenced again
in the comparison between a more stable Unit 2, with two psychiatrists,
and a more chaotic Unit 10, covered by one locum tenens and
whatever additional help could be arranged for him that week.
g) Minutes from the Safety/Risk Management Council indicate that
smoking “causes disruption among patients.” Elimination of smoking,
in addition to being a wellness initiative, may present an opportunity to
reduce problematic behaviors on the unit.
h) Incidents of client injuries are tracked by a different subcommittee than
staff injuries. This data should be correlated with a combined action
plan.
Recommendations:
a) This facility is potentially exposed for suicide risk with non-compliance of use
of the reassessment tools. The Medical Director and Administrator should set
expectations for 100% compliance. Quality should continue to monitor.
b) Quality should drill down further with data to determine why assault rates
increase with higher census levels. Care should be taken, however, not to
set a threshold too high at any census level for numbers of assaults without
action or intervention. MANDT training should be completed. The hospital
should continue daily monitoring of potential hot spots, staffing, and census
by upper management. Further investigation should occur relative to the
appropriate use of seclusion/restraint to prevent patient assaults. The facility
needs to be cognizant of the high number of new hires for Unit 10, in that a
disproportionate number of inexperienced and untrained staff will now be
providing care on this unit. Coordinate tracking and action plans for client and
staff injuries.
CSH – MILLEDGEVILLE
1. Chart Organization and Content –
Findings: Long term clients had thick charts, some with very old information.
However, pertinent information which should remain was removed from some
charts, including admission H&Ps and comprehensive psychiatric evaluations.
One patient’s chart noted a positive PPD in 1992 with a note not to give another
PPD due to a protein reaction, but there was no documentation of whether TB
had been ruled out and no chest X-ray or follow-up testing. Because of the
56
amount of time elapsed, this is probably due to chart thinning rather than lack of
follow-up, but this can not be stated definitively.
Chart order did not allow for ready identification of legal issues. Forms were
found in different sections of the chart authorizing continued stay or habilitation.
Charts generally were better organized on Forensics than AMH, so it was easier
to follow flow of medical and psychiatric issues on the forensic units.
Some Nursing documentation in longer-term charts appeared clearly templated,
with monthly notes identical from month to month. This was also seen with some
behavioral documentation on the DD units; the notes were identical month to
month.
Social Service assessment uses a relativity new assessment form with a
recovery section. This section was inconsistently used in the DD units, with some
completely filled out and others blank. The surveyor was told on at least one
occasion that this section was not applicable on the DD units, although it was
observed in the chart to be completed on more than one occasion.
The psychiatric history tab in the charts was a blank section. Staff stated that
this was due to the creation of two new forms which incorporates the history into
the unified assessment. Forms and documentation were not found to be divided
into helpful sections, so locating information was difficult and time consuming.
Infection control stickers were noted on some charts to alert of necessary
precautions, however, their use was inconsistent and it was unclear whether they
are updated or renewed periodically.
Recommendations:
a) Develop and/or adhere to a medical records policy that defines chart content
for long term clients. Remove older documents which tend to clutter chart
and make location of relevant information difficult. Critical information such
as admission H&P, initial psychiatric evaluations, etc. should be left intact.
Consider centralizing and assigning this task to Medical Record Personnel
rather than unit staff who, without adequate training, unknowingly contribute
to an inconsistent policy implementation of chart content and order.
b) Maintain a consistent order to charts to readily allow locating documents.
Tabs that assist with organization should be updated along with the forms
found within them.
c) Documentation on long-term clients may start with a template, but should be
individualized and updated with current condition and status.
d) Infection control stickers should be applied consistently, updated, and
supported by chart documentation.
2. Programming –
57
Findings: Programming on Hopeway and Freeway provided treatment options to
adult mental health patients. Groups were observed to be well run and
engaging, group participation and content were noted as positive. Most patients
were observed to leave the units to participate in the programming in the
treatment centers.
On the Child/Adolescent Unit, each patient reviewed had only limited hours of
active treatment scheduled per week, but did have four structured hours of
education per day. The school is operated by Masters-level teachers, and
attempts were made to coordinate with the home/community school in which the
patient is enrolled. It was noted from sign-in sheets that patients are allowed to
opt out of groups, and many sheets showed blanks or documented that patient
“refused” or was “unable to attend”. Charts showed documentation of
encouragement to participate in treatment, but there was lack of follow-up by the
treatment team and the physicians to formulate an intervention for the refusal of
therapy and/or non-participation in group or school. There was a daily
disconnect between the needs (group assignments) documented on the
individual treatment plans and the census sheet, and the provision of services
(group attendance) documented on the sign in sheets. In the unit secretary’s
office, there were large piles of sign-in sheets and other documents, not filed and
in disarray, suggesting a lack of monitoring, coordination and oversight. The
policy for active treatment programs/monitoring does define a process for
addressing noncompliance, but allows for participation in only one treatment
program daily. There was no substance use/abuse programming noted for C/A.
A variety of off-unit activities were available for the DD population, including work
and therapeutic programs. Groups were well run and started on time. Patients
were encouraged to participate and staff interacted well with individuals.
However, many groups, both on and off the units, did not seem to have specific
goals. Others had goals, but they did not necessarily relate to treatment
objectives. This was not due to the quality of the group, but rather a
documentation/planning deficiency that could be readily corrected. For example,
a patient may have a treatment objective to be able to pick up and hold specific
objects such as a toothbrush, coins etc. This objective of improving patient’s
grasping abilities could be assessed and monitored in group therapy if the
treatment objectives were more generic and the patient was encouraged to hold
pen, paintbrush, etc in the arts and crafts group, and their progress monitored
and recorded there.
The Powell building is designated as adult mental health, however it often
contains a mix of patients. On the daily census, several patients were classified
as “detox” and “A&D” (alcohol and drug). In addition, jail hold patients were often
housed on Powell, disrupting the milieu and unable to attend groups in Hopeway.
12 step groups were not available, and there were only minimal substance abuse
groups.
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Recommendations:
a) Define a procedure for addressing non-compliance with group attendance,
such as discussion in treatment team, active interventions, etc., with chart
documentation reflecting actions taken.
b) Enhance substance use/abuse/addiction programming on all units.
c) Particularly on the DD units, but relevant to programming everywhere, assure
that goals of group therapy relate to individual patient treatment objectives so
that group therapy providers can monitor, evaluate, and record progress that
is useful in the overall evaluation of patient progress.
d) Incorporate as much information as possible into the formulation of behavior
plans, including progress notes, group therapy notes, treatment team
feedback and discussion, and physician evaluations.
Expedite the
implementation of behavior plans to maximize benefit of interventions.
e) Effectively use the model of treatment choice and options that have already
been created on Hopeway and Freeway to address the mixture of
populations/diagnoses on the units (particularly Powell). For example, if
forensic “holds” continue to be housed on Powell, Hopeway programming
could provide groups targeting this population. Powell patients with a primary
diagnosis of substance abuse or addiction could opt out of mental health
groups in the Hopeway Treatment Mall in favor of recovery programming if
these were made available.
3. Physician Documentation –
Findings: Special observation/ precaution orders were not consistent with
admission diagnosis or initial assessments.
Physician documentation supporting the use of antipsychotic medications was
absent on several patients, and others lacked documentation of attempts to
reduce the dose.
On the Child/Adolescent Unit, physician progress notes were scanty and did not
appear to be daily. One chart was noted not having a physician progress note
for 7 days, and only 4 in an 11 day period. Rationale for medication use was
absent in the physician notes of charts reviewed.
Physician signatures were lacking on Treatment plans and telephone orders.
Physician progress notes related to lab findings or diagnostic testing were rare.
Use of abbreviations not on the approved list was noted, and staff was unable to
interpret.
Some sections of the Physician Admission Assessment forms were not always
filled out, most notably the Risk section.
Recommendations:
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a) Improve documentation supporting the use of medications, including purpose,
rationale, intended effects, justification for combination/dosage of drugs, and
contraindications.
b) Insure that admitting orders for special observation or precautions are
consistent with admission diagnosis and initial assessment. Although this
issue is addressed under physician documentation, this also could potentially
be impacted by adding a nurse to the admission unit, who could assist the
physician with the clinical assessment and alert the physician to special
observation needs, requesting appropriate precautions to be ordered.
c) Adhere to standards for progress note documentation set by the medical staff
rules and regulations. On some units, this may take additional medical staff
before this can be accomplished, on other units (C/A) it is a matter of
monitoring and enforcement.
d) Physician signatures lacking on treatment plans and telephone orders should
be flagged for completion.
e) Conduct an education campaign for the elimination of prohibited
abbreviations and use of approved abbreviations. Make some kind of
accommodation for agency staff to have access to this list (currently in the
computer system to which they do not have passwords) so that nursing can
assist in monitoring compliance.
4. Seclusion and Restraint –
Findings: As in all previously reviewed facilities, use of seclusion and restraint
was very low. C/A reports no restraint use in the past 10 years. However,
increased use of “stat” or PRN medications could suggest the use of chemical
restraints.
Most charts on Binion were deficient in at least one type of documentation for
seclusion and restraint, including family notification, plan of care, debriefings,
revision in treatment plan, and signatures.
Manual restraints reviewed on Phoenix were done well and very thoroughly
documented. Complete documentation for the use of protective devices was not
always present, including reasons for use, consents, and orders. Mittens on DD
clients were observed to be appropriately ordered to prevent patient from licking
medications off their hands. Other uses of mittens, however, could be
interpreted as a restraint when used to keep a patient from “mouthing her hands”.
In these cases, procedures for restraints were not followed and behavioral plans
were not in place to address reduction of behavior.
Surveyors were present on units during more than one code yellow, and staff
responsiveness was very good, including physicians.
The Nursing Assessment only lists four options for what patient can choose as
interventions for “what would help you if you lose control” – 1. Go to my room, 2.
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Go to quiet room, 3. Go to Seclusion Room, or 4. Be restrained. Patients need
more positive options.
Recommendations:
a) Evaluate “STAT PRN” utilization to assure that medications are not being
used as a chemical restraint.
b) Expand options presented to patients on admission and recorded in the
Nursing Assessment that are interventions that the patient can choose for
“what would help you if you lose control.” Currently listing only “1. Go to my
room, 2. Go to quiet room, 3. Go to Seclusion Room, or 4. Be restrained”,
patients need more positive options to choose from.
c) Treatment teams could be used as a method to monitor completeness of
seclusion and restraint documentation. On short term units, this would be
possible in routine treatment teams. On longer term units, the use of
seclusion or restraint may be used as a trigger for an unscheduled treatment
team, serving a dual purpose of documentation monitoring and providing an
opportunity for treatment plan evaluation/change in response to the use of
seclusion and/or restraint.
d) Review policy and training for the use of protective devices on DD persons,
clearly defining the difference between behavioral restraints and protective
devices. Integrate behavior plans into the use of both of these interventions.
5. Medical Management –
Findings: Of significance and certainly worth noting, the patients at CSH present
with the most severe mental illness and medical complexities of those seen in the
state system, and these two factors by themselves present significant challenges
in the evaluation and treatment of these individuals. Additionally, when these
factors are coupled together, issues of difficulty in diagnosis and treatment
resistance and/or non-compliance in the management of their disease are also
presented, and exhibit themselves in physical symptoms, status, and long term
treatment success/failure rates. The surveyors were aware of the difference in
acuity of patients in this facility, and recognized how this reflected in the overall
evaluation of care.
With this in mind, however, the lack of a staff internist or consulting physician to
address patients’ physical needs becomes more striking, and was evident in the
medical management of patients, especially of the more difficult or challenging
patients. Notably, there were some charts with lengthy medical problems that
were thoroughly addressed with appropriate consults with prompt follow up on all
recommendations made. One chart showed excellent control of seizures in a
patient with complex medical problems. Another chart exhibited excellent pain
scales, with intervention and response with medication as appropriate until pain
was resolved. A good relationship with the local hospital, Oconee Regional
Medical Center, existed for emergency care. Difficulty referring for specialized
consults to address advanced treatment needs before they rose to the level of
emergency care, however, was absent. History and physicals are performed by
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the admitting physician, and not by an internist or family physician, with no
evidence of follow-up by consultation with a specialist even in cases of medical
complications. Some of the specific issues that follow here in relation to medical
management would be well addressed through the use of family physicians or
internists on the medical staff serving in a consultation capacity.
Several issues were noted related to diabetic care. The sliding scale approach is
used throughout the organization, even in the long term population, and it is not
consistently implemented or well documented. Scales and related dosages
differed, patients were noted to frequently refuse finger sticks, scales were only
done on alternate days, all contributing to less than optimal diabetic
management. This was also evidenced by many diabetic patients having high
hemoglobin A1Cs (>7%), and some patients consistently having fairly high
fasting blood sugars, indicating inadequately controlled diabetes. Orders were
frequently seen to notify a physician only if blood sugars were <50 or > 400, so
routine glucose levels of 300 on long term patients often went unnoted by a
physician without a change in insulin therapy. Abnormal glucose levels obtained
through bedside testing (fingersticks) were not always confirmed through
laboratory testing even when values were above reliable readings on the
glucometer.
In addition to refusals of glucose monitoring, there were refusals of medication
documented. Non-compliance with medical care is challenging and poses a real
dilemma to optimizing care for this patient population.
Monitoring of glucose levels and documentation of medical issues frequently
associated with diabetes was frequently absent in the charts reviewed. One
diabetic patient had blood sugars ordered monthly, but no value could be located
for May or July, and the value for June was high at 171. Multiple other reports on
the chart dating back a year made it difficult to locate current data. Diabetic
retinal care and foot care was not well documented. There was also a lack of
nutritional correlation with glucose levels; diet content was not recorded as per
nursing policy.
Another general area of care which was problematic was in the treatment and
management of hypertension. Orders were noted to “hold blood pressure
medications” when a systolic pressure fell below parameters, generally below
100, however, there were no further blood pressures ordered later in the day to
reassess the effect of holding medications. There were occasions noted where
blood pressures were elevated later in the day and the medications were still
held. Most of these incidents involved the holding of more than one medication.
When medical consults or additional diagnostic testing were ordered, prompt
follow-up on consults/testing was not always present. Several charts with
abnormal tests or monitoring of drug levels had no further documentation of a
recheck, or follow-up in progress note or physician orders. Pharmacy and
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neurology recommendations of checking therapeutic drug levels and performing
an annual review were not completed. Standing lab orders to periodically check
medication levels were noted not to be always done in a timely manner.
Some diagnoses were inadequately supported by discussion or formulation.
Patients with the diagnosis of “dementia” had no documentation of MMSE or any
other instrument to evaluate cognitive function. There was no documented
metabolic work-up found in the charts to assess the reversible causes of this
illness. Other DD patients with psychosis NOS and autism had no supporting
documentation as to why patient was labeled with this diagnosis.
On Phoenix, several charts showed repeated diagnostic conflicts between chart
forms.
No documented pacemaker checks were found for patients with pacemakers.
Substance abuse assessment and treatment was weak, as it has been
consistently throughout the surveyed Georgia hospitals. This diagnostic category
was not specific or consistently related to clinical presentation. Diagnosing
substance use vs. substance abuse vs. substance dependence is important in
deciding treatment modalities and in the end, good recovery. There was an
absence of risk factors associated with withdrawal documented in the chart, and
medical issues commonly associated with substance abuse were also left
unevaluated.
Surveyors noted increased incidence of decubitus ulcers on Craig.
(Also
addressed under PI sections and Staff Training section) Nutritional assessments
do not appear to address nutritional considerations as related to skin integrity.
No standing orders were found for PRNS, which was commendable.
Use of multiple antipsychotics simultaneously was observed, and there was no
documentation to explain the purpose of the medication combination or dosage.
Supporting documentation of justification or rationale for use was noted to be
lacking in several charts.
Medication reconciliation, a recent JCAHO initiative that assures accuracy of
medication tracking from prior to admission (“home list”), through hospitalization,
including transfers between units or facilities, to the discharge of the patient was
not noted. The practice was not observed in the charts, nor were there forms or
policies that supported the process.
Routine checks and performance of Fleets enema for prevention of bowel
impactions were observed in chart documentation, but no notes reflected
attempts at evaluation or alleviation of the problem by medication adjustment or
diet changes to relieve constipation.
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STD testing on patients with high-risk sexual behavior was absent on several
charts. On other charts, patients who tested positive for syphilis were not further
tested for other STDs such as HIV.
Recommendations:
a) CSH could clearly benefit from the addition of family physicians, internists, or
perhaps other specialists to practice at CSH in their specialty; currently they
are used mostly to substitute for attending psychiatrists on the units. At the
very least, executed contracts for family physicians/internists or specialists for
routine and advanced medical consults or treatment would expedite proper
medical care for complex situations.
b) Several recommendations are made in the management of hypertension.
When medications are held due to low blood pressure readings,
reassessment should occur at least once per shift and findings relayed to the
physician if abnormal. If blood pressure continues to be low for more than
two days, then re-evaluation of medical regimen and/or status should occur.
This can become especially crucial when using beta-blockers and centrally
acting anti-hypertensives because of their potential adverse effect caused by
abrupt withdrawal. Overall, anti-hypertensives are complex agents requiring
skilled medical direction, direction that is beyond the routine skill set of most
psychiatrists. This again suggests the need for staff physicians or contract
specialists who manage the medical needs of the patients.
c) Some of the behavioral problems associated with dementia could be
addressed by the prompt use of a combination of a cholinesterase inhibitor
and a NMDA receptor antagonist (i.e. Aricept and Memantine) instead of
adding a neuroleptic.
d) Protocols for the management of the diabetic patient need to be established
and/or followed. This should include but not be limited to foot care, retinal
care, frequency of Hgb A1C testing, interventions for refusals of both testing
and medication, and more specific procedures to follow for abnormal test
results (both glucometer and lab results). Use of the sliding scale approach
should be limited and not applied to long term management of diabetes.
When the sliding scale is used, the facility should standardize its use. The
use of a flowsheet or the establishment of a diabetic care team may be
considered to address this problem.
e) Procedures for the diagnosis, medical management and treatment planning
for the substance abusing/chemically dependent/substance using patient
need to be better defined, including identification of risk factors for withdrawal
and the medical complications commonly associated with these diagnoses.
f) The increase of decubitus ulcers on Craig should not be dismissed with the
recent QI study conclusion, and efforts should continue to reduce the
occurrence of bed ulcers.
g) A procedure and associated training for “Medication Reconciliation” needs to
be established and implemented.
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h) STD testing should be done routinely on patients with high risk sexual
behaviors, or if already testing positive for one STD, additional testing for
others should automatically follow.
i) Although bowel management seems to be effective through the use of
routine/regularly scheduled enemas, evaluation of causative factors of
constipation should occur and be documented along with the interventions
taken to prevent bowel impactions. Alternatives to routine Fleets enema
should be considered.
j) A method to ensure follow-up of diagnostic tests, abnormal labs, and
consultation recommendations must be established. This could be addressed
in a variety of ways, including a focused QI project, inclusion in Treatment
Team discussion, assignment of duty to a specific shift/staff member, change
in chart order to highlight new test results, etc.
6. Utilization Management –
Findings:
For the DD population, de-institutionalization is appropriately
proceeding, to help patients live in the least restrictive environment; however, the
supports in the community for crisis intervention do not appear adequate to
handle the normal behavioral variability of DD persons. This leads to premature
and/or unnecessary admission to CSH, disrupts the lives of DD persons, and
conflicts with patient’s rights to live in the least restrictive environment. Also, if
individuals are no longer dangerous to self or others, justification may not exist to
continue the level of care in an institutional setting versus a community setting.
APS tracking data indicated an increase in unauthorized days from March – June
of 2007. The UR Coordinator indicated that this was due to a data entry problem
rather than a true issue.
As in other facilities, APS data was not necessarily used for justification of the
establishment of the 23-hour observation unit. The unauthorized admissions to
inpatient units were not seen as the potential admissions to the 23-hour
observation unit.
Data from a Performance Improvement project on 30-day
readmission rate was referenced as support for the creation of the 23 hour
Observation Unit, and readmission rates are expected to decrease. The unit is
too new to have data to support or refute this supposition. Criteria for
differentiation between admissions to inpatient vs. admissions to 23 hour
observation have been created. On the day of the survey, a patient was noted to
have been in the observation unit for well over 24 hours, actually approaching 48.
This was against policy.
Though APS data are tracked and compared to other facilities, information such
as number of unauthorized days or length of stay per physician is not used for
internal utilization management.
The usefulness of this data system is
questionable in light of staff report that it is very labor intensive.
Recommendations:
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a) Many patients on the maximum security unit have been referred in by other
psychiatric hospitals or prison systems due to out of control behavior. CSH
then takes responsibility for their discharge and is largely unsuccessful in
referring them back to or placing them in their respective community system.
A system should be developed whereby if CSH admits and stabilizes the
patient, they must be accepted back to the referring hospital into a lower level
of care or for pursuit of continued placement in their home community.
b) Enforce compliance with no more than a 23 hour stay in the 24 hour
observation unit.
7. Treatment Plans and Team –
Findings: Treatment Teams were attended on Binion, Freeman, Crittenden,
Powell and Piedmont.
Forensic treatment teams are held on admission, every two weeks for two
months, once a month for the remainder of the first year and then quarterly
thereafter. Morning team on Binion was fully attended by all disciplines which
were knowledgeable about the patients, including their diagnoses, clinical
conditions and changes, and forensic status and plans. The team discussed
patients’ complaints of pain with appropriate interventions. Patient’s participation
in team discussion was minimal, and was not encouraged by active listening or
response to patient comments. One patient appeared sedated, slow in
movement and limited in responsiveness, so his involvement was minimal. The
afternoon team was missing Activity Therapy due to staff vacancies. It too was
well run, with the patient spending a considerably longer time in the meeting and
participating at a much higher level. The team was very recovery oriented and
provided individualized approaches to each patient’s care.
Freeman’s team
meetings were also done well with team and patient engaged in review and
planning.
Team on Powell was also well run with good patient participation.
Nursing led treatment team on the C/A unit with good interdisciplinary input.
Staff displayed detailed personal and clinical knowledge of the patients
discussed, and they did an excellent job of individualizing each child’s plan. As
discussed under programming, however, there is no defined procedure or system
for establishment, monitoring, and response to minimum treatment
hours/involvement either for the unit as a whole or per child.
Treatment plans throughout the system were often lacking in inventory of patient
strengths and needs. Although progress notes were generally good, there could
be better correlation between the progress note content and the development or
adjustment of the treatment plan, especially on C/A. Patient signatures were
lacking on many plans.
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The Piedmont Team meeting was well conducted and appropriate to the client.
Family was notified but unable to attend. Staff indicated that they would be
notified of the findings, and recommendations. On the DD units, treatment plans
were not always consistent with the Client Centered Planning document, and
staff confirmed that it was referred to on admission and then upon transitioning.,
indicating that it is not always integrated into the treatment plan while at CSH.
Medication reduction strategies were not noted on any treatment plans reviewed.
Behavior Plans were noted to not always be updated, reviewed, or implemented
as directed.
Treatment plans were noted that did address medical needs of terminal lung
cancer and a fractured jaw. Pain assessments showed good follow-up and
interventions.
Recommendations:
a) Coordinate treatment plans with client centered planning, so that this is not
only referred to on admission and discharge, but all through the treatment
process
b) Use treatment team to address issues of non-compliance with medication
and/or group therapy participation
c) Use progress notes in the formulation of the treatment plans
8. Patient and Family –
Findings: Medication consent forms listed as many as six different medications
on one sheet with the patient’s signature. This would theoretically allow adding
medications after the patient has already signed. Medication consents were also
found unsigned by patients on Freeman and by parents on Crittenden. More
significantly, the consent form provides no evidence that actual risks, side
effects, benefits and alternatives were actually discussed with the patient,
thereby confirming that consent is actually informed.
Chart evidence of involvement of family in the treatment of Children and
Adolescents was limited to signatures for consent for treatment and a medication
change being discussed with one mother.
Charts in Phoenix exhibited excellent involvement of family including informed
consent and education of effects of medication, even when parents were not
legal guardians.
Visitation areas were observed on all units, providing privacy in a safe
environment. Visitation times were somewhat limited, especially considering the
state-wide referral base of CSH.
The admission area for all patients was detached and “sterile”, with a separated
glass viewing area with metal detector that all patients passed through before
67
being allowed staff contact in the building. This left an impression inconsistent
with a recovery philosophy.
By its own report, the facility lacked a “patient advocate” or “consumer specialist”
position, although they did hire former patients and had employees acting in the
capacity of responding to patient/family complaints. In staff interviews, the
process of the investigation was explained to be mainly information gathering. If
the result was the generation of a CIR (Critical Incident Report), the process
continued through Risk Management channels. If no CIR was necessary, the
information was given to the Clinical Director of the unit involved, who responded
to the patient/family and was also responsible for addressing any problem
identified. There appeared to be no closure to the loop to insure that appropriate
actions had been taken to address the specific complaint, or to identify the
problem as a quality issue that needed further follow-up.
Recommendations:
a) Revise the patient consent form for medications so that each medication
entered has the date and signature only for that medication, and allows for
evidence that patient was informed of the risks, benefits, side effects, and
alternatives.
b) Especially in light of the huge referral base for CSH, make sure that visiting
hours are adequate to allow families time for visitation, or clearly
communicate that accommodations can be made outside of posted hours if
prearranged.
9. Training/Staff Development –
Findings: Staff on C/A did not know what a “developmental assessment” was.
Nursing staff on Phoenix believed it was a policy violation to leave the inner
cabinet door in the medication room unlocked (as it was found). However, upon
review of the policy, this practice was allowed.
MANDT training has been progressing according to the planned timetable
despite scheduling challenges created by staffing shortages which make it
difficult for staff to leave units to attend training.
Review of skin ulcers on Craig revealed a misidentification of a stage two ulcer.
By chance, three of the five employee files reviewed involved staff that were or
had been transferred between units. Training records were not observed and
could not be presented that showed basic safety orientation had occurred.
Recommendations:
a) Retraining may be indicated in the identification of skin ulcers.
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b) For staff that transfer between programs and for staff that regularly function
on multiple units, namely “on-demand Health Service Technicians,” unit
specific orientation should occur timely and be documented
10. Safety/Environment of CareFindings: Although this facility is older than the other state buildings, surveyors
were impressed with the many safety and aesthetic factors that had been
addressed to make the environment more safe, pleasing, and functional.
A
suicide risk assessment of all patient bathrooms had been conducted and many
renovations had already occurred. This included plumbing, stall door, hinge and
partition modifications. Other risk factors still existed, however, some in the
same rooms where these other modifications had already occurred. These
included such things as grab bars and tile soap dishes with handles in shower
and bathroom areas. Less expensive measures such as discontinuation of use
of plastic bags in patient areas and elimination of telephones with removable
cords and wires had also not been taken. Belts, shoelaces, and cords were
evident and still allowed on most units. On some units, TVs and other audio
visual equipment were secured in response to a previous incident in order to
eliminate breakage or tipping with resulting injury, however the use of carts with
the same equipment was still being utilized by staff when bringing in videos to
groups. All such equipment should be stabilized or eliminated so that this hazard
is eliminated.
Lightweight chairs were present in group areas of the Freeman unit, which could
easily be picked up and used as weapons. In a group setting, this is even more
dangerous as more than one patient could get involved and create and unsafe
situation.
With the exception of one unit visited, patient rooms were well kept, neat, and
clean. Long term patient rooms were homelike and personalized. The exception
was the 1st floor in the Allen Building, where rooms and bathrooms were
disorderly and unclean.
Some computers were noted to be over 10 years old. Agency staff cannot fully
utilize computers (not given passwords), resulting in limited access to information
such as approved/prohibited abbreviations, policies, etc.
Much needed bathroom renovations on the first floor of Allen were in progress.
Interim Life Safety Plans were in place. The newly renovated area still requires
benches or chars for disabled clients in the shower area. Notably, this was the
only area on the facility safety walk-through where an unlocked door which
should have been locked was found. The unlocked door was a laundry chute
that was open. This is remarkable and very positive, considering the literally
hundreds of doors in this old facility and the frequency of this occurrence in the
other facilities surveyed.
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It was commendable that with the exception of a few long term residential clients,
this was a non-smoking facility. Fresh air breaks had replaced smoking breaks,
and patios originally provided for patients to smoke on had become outdoor
porches.
Recommendations:
a) Evaluate the use of lightweight chairs in group settings due to the ability to be
used as weapons. A short term fix could be attaching chairs together so they
cannot be lifted.
b) Easily removable hazards such as telephone cords that can be detached and
plastic bags should be eliminated from patient areas. Belts, shoelaces, and
removable cords should also be eliminated, limited and/or closely supervised.
c) Review areas where physical renovations and safety modifications have
already occurred to identify remaining hazards that create an unsafe
environment.
d) Secure TVs and/or eliminate audio/visual equipment on carts to prevent
tipping with potential injury to staff and patients. Technology allows for
remote access of equipment for videos if necessary.
11. Nursing Practices–
Findings: There is no point of distribution system (Pyxis) for medications,
although systems are in place to limit floor stock, monitor controlled substances,
and prevent stockpiling. There is no pharmacist verification prior to med
administration after hours (nights). The medication is verified by the physician,
and the pharmacist on call can be contacted if necessary.
Policy indicated that multi-use vials of insulin could be used till expiration date.
This practice is questionable and deserves further investigation as most multiuse vials expire 28 days after opening.
Multiple medication rooms and medication carts were inspected, and most bulk
OTCs, controlled substances, and medications were in order with none expired.
However, one medication room had a plethora of expired medications and food
products, some with dates as old as 2005. These were removed immediately.
New medication sheets are only printed every 90 days, so orders that are placed
on the patient charts are not always reflected as current.
Recommendations:
a) Review policy of expiration of multi-use vials once opened to insure that it is
consistent with manufacturers’ specifications.
b) Establish a nursing policy and practice for inspection of expiration dates in
medication rooms. No expired medications or supplies may be kept in the
unit medication rooms.
c) Consider printing new medication sheets more frequently than every 90 days
to reflect current orders on the chart.
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12. Staffing, staff morale and attitude –
Findings: Staff morale is positive despite shortages in staffing on most levels
and other challenges presented by the system. Generally, there seems to be a
team spirit in addressing problems. There is an impression by staff that there is
a commitment to improved quality, and in fact, they feel that patient care has
improved over the last several years, with recognition that they still could do
better. Genuine caring was exhibited by staff, and they generally appear
attentive to the needs of the patients. The most frequent response by personnel
queried to identify the facilities number one need was staffing, both in quality and
quantity. Other concerns expressed by staff potentially affecting morale included
excessive and inefficient paperwork, patients being admitted who were
inappropriate and/or medically unstable, and old/outdated computers
As in the other facilities, vacancies occurred throughout the institution on many
levels. Human Resource data showed significant vacancy rates for Nurses,
Techs/CNAs, Physicians, Psychologists and Behavior Specialists, Pharmacists
and Social Service Providers. Also as in other facilities, a large number of
employees have very long tenures, and their imminent retirement threatens to
only exacerbate staffing problems in both numbers and by loss of these highly
experienced, committed and skilled staff.
Excluding supervisor, charge and management positions, data show that the
facility operates with only 20% of their line staff nursing positions filled, with shifts
covered either with agency nurses, through the use of mandatory overtime, or
with supervisors performing clinical duties in addition to their administrative
functions. Nursing shortages were evident in practice throughout the survey: the
Admission unit was run by a non-nursing professional, there was only one RN
assigned per building for 2nd and 3rd shift, staff complained of mandatory stayovers (overtime) to cover shifts, and supervisors being called suddenly to cover a
shift due to an unexpected call-in. The position of “Team Leader” attracts nurses
away from nursing positions due to higher pay scale, although a nursing degree
is not required. This depletes the internal nursing pool and adds to the
shortages.
With a lack of forensic psychiatrists, the Clinical Director meets weekly with the
medical staff consisting of a general psychiatrist, a neurologist, two surgeons,
and an anesthesiologist, and a sole forensic psychiatrist for supervision and case
review. While the non-psychiatrists had considerable institutional longevity, the
lack of medical specialty expertise in Psychiatry and especially Forensic
Psychiatry was striking.
Child/Adolescent was the most adequately staffed with a C/A Psychiatrist and a
general psychiatrist.
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An “on-demand” Health Service Technician pool was created to readily provide
staff as needed to cover scheduling needs created by acuity or call-ins. This is
essentially a PRN pool that reports to work and is assigned as needed. Although
this is a creative way to address staffing needs, it also points to the frequency
and volume of unfilled shifts, call-ins, and increased acuity needs. The
qualifications, experience and background of Health Service Technicians
continue to be of question as the primary caregivers in this environment.
All individuals with a DD diagnosis need to have a QMRP (Qualified Mental
Retardation Professional) involved in the program design and implementation of
their treatment. This is true whether they are in an ICF or Nursing Home
environment. It was not evident that this was the case for patients in the Craig
Building.
The unit secretary on C/A was backlogged on filing and shredding duties due to
other responsibilities such as greeting visitors, answering phones, entering
computer data, and performing forensic and human resource paperwork. As
noted earlier, this contributed to lack of treatment coordination in monitoring
group participation and compliance.
One psychologist for 192 forensic patients is not adequate and contributes to a
backlog of evaluations and slows the legal process.
Pharmacy staff members are operating with almost half of budgeted positions
unfilled, and hiring is practically nonexistent (last hire 20 years ago). Pay and
call requirements make recruitment difficult. Looming retirement schedules make
existing staff relatively short term.
Recommendations:
a) Address staffing shortages in all areas with an aggressive recruitment plan,
including examination of salary levels to remain competitive. Although all
areas are in need of attention, physician staff, nursing staff, psychology and
pharmacy appear to be the most critical areas. Awareness of the impending
retirement and continuing loss of long term experienced staff is essential.
The relatively rural location of the facility should also be factored into the
ease/difficulty in recruitment.
b) Consider restructuring the pay of Team Leaders so as not to attract Nurses
out of staff/management positions depleting the nursing pool internally.
c) Staff the admission unit with an RN will improve the admission process and
eliminate potential risk issues. Facility data shows the average time spent by
patients in the admission area is 94 minutes. This reflects 94 minutes without
health professional assessment and oversight, and the inability to take orders
from a physician.
d) The scheduling pattern of only one RN per building for 3-11 and 11-7 shift is
inadequate.
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e) Consider letting the staffing coordinators who manage the Health Service
Technician “on-demand” program also handle nursing staffing, relieving
Nurses of this responsibility. This would be particularly helpful to Nurse
Managers who perform administrative and line staff duties.
f) Review staffing to insure that QMRPs are appropriately involved with DD
programs and persons.
g) Look for staffing efficiencies in the system. For example, there is an extra
layer of supervision between the Nursing Manager and the Nurse Executive
on the C/A unit. Considering the significant downsizing of institutionalized
patients over the years, coupled with the number of long term employees, this
suggests that some employees may remain in “layered” positions that are no
longer needed.
h) Create efficiencies with upgraded computers and technology, which also will
contribute positively to staff morale, as this issue was frequently identified by
staff as a frustration.
13. Risk Management –
Findings: Treatment team on Binion was conducted with the patient sitting by the
only door in the room, effectively preventing staff exit. Considering the violent
histories of these patients, this is unadvisable.
On the C/A unit, it was noted that there were two patients that shared the same
surname. Policy for client identification requires “Name Alert stickers” be placed
on stamp plate only, which is inadequate to prevent patient mix-up or confusion
of charts themselves or other forms/documents.
The safety system for patient observation and privileges did not always correlate
with patient clinical condition or status. Clients on less restrictive levels were
observed to still have documented high-risk behaviors. This disparity was also
seen later in patients with longer lengths of stays, where privileging did not match
level of behavior. For example, patients who were allowed to attend activities off
the unit with minimal escort or supervision did indeed have these privileges
granted, but this was inconsistent with their documented aggressive behaviors or
levels of observation status.
It was noted both by observation and by review of policy that staff who have
regular patient contact are allowed to wear heels and open-toed shoes. In
general, this is unadvisable for patient care areas and especially in an
environment where patient-staff assaults occur.
Issues related to patient assaults were encountered by surveyors frequently
throughout the survey, as these were noted during discussions at treatment
teams, documented in charts by medical conditions that were a result of an
assault, seen in the review of incident reports, and one surveyor witnessed an
attack on a physician. The issue of the lack of admission orders for special
observation and precaution is relevant here, as sometimes precautions were
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implemented after an event, which may have been prevented if orders had been
issued earlier.
Surveyors requested to review a sampling of CIRs (Critical Incident Reports) to
include examples of incidents of patient-staff assaults, patient-patient assaults,
suspected or alleged abuse, attempted suicides, falls, and medical conditions
that escalated and required transfers or emergency care. An example of an RCA
(Root Cause Analysis) was also requested to review. The intent was not so
much to examine specific incidents themselves but rather the process in place for
investigation, action-plan formulation, and follow-up. CIRs were found to be
minimal in write-up of investigation of causative or contributing events or factors,
or actions taken to address reoccurrence. Appropriate actions were taken when
an employee disciplinary process was indicated, including suspensions and
terminations; however, from a quality perspective, there appeared to be lost
opportunities for improvement. On the DD units, a number of “unobserved” or
unknown incidents were reported, and CIR reports were also noted to conclude
that incidents were “unpreventable.”
Incident reports deemed to need further review are sent to an IAT Team (Incident
Analysis Team), however, it was not clear how these were identified and meeting
records. Meeting records reflect only 7 meetings thus far this year, once in
January, twice in March, then once again in April and June, and twice in July.
Minutes reflect minimal review both in quantity and quality.
Root Cause Analysis (RCA’s) were likewise found to be very scant in data,
analysis, and outcome. It was apparent from examination of documents and
interviews with staff that there is a disconnect between Risk and Performance
Improvement. The closure of the loop in the investigation of incidents did not
always occur, insuring thorough investigation and follow-up and evaluation of the
implemented action plan.
Another committee called “FMEA” (Failure Mode and Effects Analysis) conducts
studies and tracks occurrences over a longer time period. Studies in progress
through this committee include “hand-off communication,” patient falls and
manual holds. Some of these data have been tracked for over two years. Staff
is proud of the efforts of this committee, and cites good relationship with the local
community hospital and decreased falls and manual holds as positive outcomes.
Recommendations:
a) Review policy for “name alerts” for occurrences of multiple patients with the
same name to adequately prevent mix-up.
b) When meeting with patients, either alone or as a group, advise staff to
routinely position themselves so that they are not prevented exit from a room
or area.
c) Review dress code for appropriate footwear on units by caregivers.
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d) Patient’s level of observation and/or privileges must coincide with their clinical
condition or status. This occurs both on admission and with continued stay.
e) Process of Critical Incident Reports (CIRs) and Root Cause Analysis (RCAs)
should be improved to reflect a thorough investigation of incidents from a
more global perspective, one that would prevent similar incidents from
happening again, rather than just an “at fault” investigation that addresses an
employee performance problem or specific issue. Areas that should be
addressed in all investigations include but are not limited to staffing levels and
ability to observe the population at the time of the incidents, when and where
incidents are occurring, whether precaution levels match patient status and
whether they are being followed at the time of the incident, procedures and
reporting measures that would identify injuries or harm immediately, and
impediments to the reporting of incidents. Although investigations can be
lengthy and time consuming, in the long run this could help to prevent or limit
future occurrences and improve patient and staff safety. Better coordination
between Risk Management and Quality Performance could lead to better
system-wide management and outcomes.
14. Quality Program –
Findings: Several Performance Improvement Committees and studies were in
place with extensive data collection and tracking occurring.
Nursing
Performance Improvement operated with a calendar to rotate studies by month in
several key areas. These included client ID, shift reporting, pain management,
documentation, assessment and seclusion and restraint. Other key aspects of
care were monitored monthly without rotation, including mediation administration
and end of life protocol. Performance Improvement teams and focus groups
addressed specific issues. The Client Safety Committee monitored other
indicators. A plethora of data was contained in charts and graphs from various
studies. Although most of these efforts were with merit and well presented, it
was somewhat difficult to track how this information was channeled through
Leadership, coordinated, acted upon, applied to the whole institution and
followed up on.
Data are appropriately tracked and cross-referenced with other variables to note
correlations or impact of variables. One notable graph contained a comparison
of seclusion and restraints against stat/PRN utilization and against staffing ratio
by unit. No correlation was noted so no specific action was taken. However,
there has been a notable increase of stat/PRN utilization over the last year.
Recommendations:
Quality does an excellent job at collecting and presenting data. The followthrough and action plans associated with these data are not always as well
documented as the initial findings. The Quality program should analyze it’s own
process of Leadership reporting, communication and coordination with Risk
Management, and methods of follow-up on the effectiveness of action plans.
Coordinated efforts can maximize the effectiveness of quality initiatives system-
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wide. Because data collection can be time consuming, limit to high risk, high
volume, and problem prone areas, and insure that the data are fully analyzed
and utilized for improvement.
Re-examine benchmarks or baselines for
indicators of when investigations, interventions or follow-up is needed.
NWRH- ROME
1. Chart Organization and Content –
Findings: The organization of charts was inconsistent, with section dividers or
tabs inserted in different order. In addition there were several charts where no
information was found behind some of the tabs. There was an inconsistency in
chart order, with physician orders in reverse chronological order, while progress
notes were in chronological order.
As generally found elsewhere, shorter-term patient charts were easier to
navigate than longer-term patient charts. Some long-term charts were very large
and contained old information that was unrelated to current patient status or care.
This made it difficult to track clinical progress and find new and relevant
information, especially current medications and medications on admission.
Annual physicals, functional assessments, and psychiatric evaluations dated
back to 2001, yet Social Work evaluations sometimes referred to previous
assessments that could not be found on the chart. There was inconsistency
between charts in what was kept and what was not. Paperwork on transfers from
other facilities was located in various places and sometimes duplicated
throughout the chart. In addition, there were a number of documents found in
several charts that were questionable in their pertinence, for example, multiple
photocopies of the same page from a telephone book.
The DD units had two charts per patient, one designated as “medical” and the
other as “legal.” This was found to be cumbersome in tracking patient progress
and clinical care. For example, treatment plans were in one chart, progress
notes in another. Forms were also inconsistently filed between the two charts.
The monthly and/or the quarterly QMRP reports were not found in the chart on
several DD units. While these were provided to the surveyor upon request, they
were found in a stack of reports that were not filed rather than in the chart.
Short-term charts were generally better organized, with the AMH charts being
slightly superior to the Forensic charts. The Treatment Plan Problem List and the
Interdisciplinary Education Record were found to be helpful.
Peel-off and sticky forms were used for standard documentation, including
refused medications and pain scales. These seemed to work quite nicely. It was
noted, however, that on occasion, these notes were hole-punched after being
completed and put on the chart. This made some documentation, including in
some cases the signature, illegible.
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There was some duplication of forms noted, both on the pre-visit document
request and as utilized in the chart. It appeared that outdated or replaced forms
were not removed from circulation when the new ones came out, and thus
continued to be used. Vital sign sheets were one of these, where the newer one
included waist circumference measurement and the older one did not.
Some unapproved abbreviations were seen in charts, for example “QD” for once
daily, and “RD” for redirection on a behavioral tracking sheet where RD was not
given as an option in the legend.
Recommendations: –
a) Establish a consistent chart order throughout the facility and monitor
compliance. Remove tabs/section organizers that are no longer in use, keep
tab titles current. Charts need to be purged in accordance with Medical
Record Policy to keep only relevant and useful information readily accessible
in the chart. Having this done by Medical Records personnel is suggested so
that the practice can be applied consistently. When specific prior reports are
referenced in an update note or assessment, care should be taken to have
that report readily available for review on the chart.
b) Identify reasons why chart filing is lagging, and take steps to address to keep
charts current and reduce loose filing.
c) Eliminate hole punches through required documentation when using peel and
stick forms.
d) Remove old or replaced forms from circulation to prevent their utilization.
e) Evaluate the utilization of two charts for DD clients in light of the misfiled
information found in each chart and the difficulty in coordinating information
between the two.
f) Review approved abbreviation list, update as necessary, enforce compliance.
2. Programming –
Findings: Programming for mental health occurred both on the unit and in the
Treatment Mall. There were two Treatment Malls, one designated as acute and
the other as rehab. The Acute Mall had a substance abuse track and a mental
health track. Mental health groups and 12 step recovery groups occurred in the
Rehab Mall.
There was still patient inactivity on the units.
At this time, there are two functioning Forensic Units, one designated as the
admission unit and the other as a “step-down” unit. The criteria for movement of
patients between the units is not established, and appeared to be somewhat
arbitrary.
The number of hours of actual active treatment and patient interaction and the
reinforcement of training objectives throughout the day for the DD clients
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appeared to be low. This may be a due to weak programming, but may also be
related to the documentation on progress of objectives. Some clients showed
only 3 or 4 times a week scheduled for work on objectives, with as little as 1-2
hours a day. What was not credited or documented is all the time that staff is
working with the clients on bathing, dressing and eating. These did not have
objectives and therefore were not counted as formal active treatment. Patients
could have training objectives tied into these activities, maximizing active
treatment, staff time and progress toward goals. It was also observed that all DD
individuals had money management and self medication objectives. Even when
the assessments indicated that some of the profound clients may have skills that
could be developed in the areas of self help, bathing and dressing, these
objectives and training needs were not addressed.
Times around shift change and pre and post meals also appear to be loosely
structured on the DD units. When no formal program is taking place, there
needs to be a rotation of attention among all the clients.
Recommendations:
a) Review programming and documentation for DD clients to maximize both
treatment opportunities and the capture of these in the record. Take
advantage of routine daily activities for training and development, and cross
reference goals and objectives between them. This may also be beneficial in
allowing the client more opportunities to complete activities related to
treatment objectives. Review “downtime” activity to assure clients receive
adequate attention and supervision.
b) Establish criteria for movement between the Forensic Units, if indeed one is
designated and functioning as a “step-down” unit, rather than arbitrarily
transferring patients due to bed need.
c) Provide adequate treatment options for individuals not going to the treatment
malls.
3. Physician Documentation –
Findings: Although some charts had excellent documentation of rationale for
medication and reasons for increase/decrease, many had none. Rationale was
most frequently noted in the dictated psychiatric evaluation, which on the AMH
units, included a section entitled “Medication Rationale.” Emergency medications
given did not have a descriptive progress note by the physician.
Admitting psychiatric assessments were thorough and well documented, and the
suicide and violence risk section were observed to be valuable.
The reason for special observation was not always described in progress notes,
and orders were not renewed every 24 hours with documented justification.
Admission orders for special observation status were sometimes found to be
inconsistent with the practice for patients on the Forensic Unit.
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Many telephone orders were not signed by the physician, or were signed late.
Also, many were not noted to be “read-back verified.” There appeared to be a
disproportionately high number of verbal orders. This may indicate orders were
being given in person rather than the physician writing the order himself, as
opposed to a verbal order given over the telephone. This is not advised, as
related to JCAHO safety goals.
The standard Admitting Physical Exam appeared thorough, but the form provided
no section for conclusions and diagnosis. The “History” part of the H&P (History
and Physical) could not be located in many charts, nor could the “Review of
Systems.”
On the DD units, it was noted that the Axis I diagnosis was not always consistent
between court reports, assessments, and treatment plans even when they were
completed roughly at the same time.
Recommendations:
a) Make the standard practice of observation level of new patients consistent
with physician orders on admission. Physicians should be informed of this
standard procedure, and if Nursing notes a discrepancy, they should contact
the physician for a revised order. Likewise, reasons for special observation
levels should be documented in the chart.
b) Chart review should occur, perhaps at treatment team, to ensure consistency
in diagnosis in the chart between forms, reports and other chart entries.
c) Verify that the use of “verbal orders” is for telephone orders only, in
accordance with Joint Commission safety goals. A quality initiative for readback verification and physician’s timely signature on orders may improve
performance in this area, as this seems to be a long-term ongoing problem.
d) H&Ps should be complete with “History” and Review of Systems included.
e) Rationale for administration of medication and changes in dosage should be
documented in every chart.
4. Seclusion and Restraint –
Findings: A commendable low use of S&R was recorded for this facility. No
seclusion rooms had restraint beds, and staff stated that if necessary, patient
beds are moved and used for that purpose. This practice was questionable not
only for the time necessary to move the beds, but as noted in Section 12, several
types of beds are utilized in the facility, and not all are suitable for use as a
restraint bed. The use of side rails on beds to prevent falling may be considered
restraint when the purpose as documented is to keep an individual from getting
out of bed.
Staff stated that there were no incidents of manual hold or mechanical restraint
used on the DD units. In some cases, it was questionable whether the failure to
use a manual hold had a more detrimental effect on the patient than if one had
been utilized.
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A policy referenced the use of a Posey restraint vest for transport of patients,
however staff stated this is no longer used. If this is not used, it needs to be
removed from policy. If it is still used, the procedure needs to state how many
staff members are to assist in the transport for safety purposes. This method
can be a contributing factor to serious injuries when used for transport.
Policies referencing the use of restraints dictated the need for “constant
supervision” during restraints. This should be revised to state 1:1 observation
since staff could be assigned other duties or patient observations and still provide
constant supervision. Policy should also address client privacy during restraint.
It was also noted that not all restraint polices stated the requirement for family
notification.
Recommendations:
a) Review utilization and associated documentation for bed rails to attain
compliance with restraint standards. Remove reference in policies to Posey
restraints for transport if this procedure is no longer followed. If it is followed,
the policy needs to be reviewed for safety considerations and precautions to
prevent falls inserted, including requirements for close staff escorts.
b) Although low use of restraint, manual holds and seclusion are commendable,
ensure that patient safety is not being compromised in order to eliminate
these procedures. When patient/staff are at risk of assault and or patient
rights are being threatened, appropriate interventions should be made.
c) Review policy terminology for patient observation during restraint, ensuring
that patients are on 1:1 observation. Also review policies to assure
compliance with family notification and patient privacy standards.
d) Evaluate the usage of patient room beds as restraint beds, both from a safety
perspective as well as from a patient rights perspective. Being restrained in
one’s own bed can exacerbate mental health issues the patient may already
have.
5. Medical Management –
Findings: In general, medical management at this facility was improved as
compared to other sites visited. The model of medical physicians acting as
attendings for DD clients with the psychiatrists consulting, and visa versa for the
MH patients, seemed to work very well. Patients who were medically ill were for
the most part promptly evaluated with dispositions made. Communication
between psychiatrist, nurse, and medical doctors appeared to be good. The use
of the physician “communication book” on the units also seems to work well for
notification and follow-up, despite creating some redundancy in documentation.
Charts were specifically reviewed for diabetic management. Overall, patients
were well managed. However, long term diabetic management through Hgb A1C
measurement was inconsistently implemented.
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Management of hypertension was also generally well addressed. However, a
few patients were on three or more anti-hypertensives. Lasix was observed to
be used in patients without a history of CHF and with normal renal functions, and
many of these were also given KCl. Clonidine seemed to be used excessively,
which is centrally acting and not recommended for patients who are already
mentally compromised.
Several patients with diagnosed dementia had no evidence of ever having a
metabolic work-up or a formal MMSE.
Bowel movement objectives were established for long term clients, and indicated
that individuals would have various monthly objectives set, such as 15, or 18
BMs a month, or even an annual objective of 280 BMs a year. Setting an annual
objective creates an extremely cumbersome system, and along with monthly
objectives, does not allow accurate identification of potential problems. For
example, an individual could have BM day 1-15 and then none for the rest of the
month, and meet a monthly objective. While a surveyor was informed that
patients also had orders for medication if they had no BM for three days,
evidence was found in multiple charts on multiple occasions where individuals
went for 4-5 days without further assessment.
There were instances of “deferred” on physical exams were noted and seemed to
be used inappropriately as they were never completed at a later time and were
reasons were not documented as to why they were not. It was questioned
whether this is a default entry that stays unless the physician enters something
else.
Several patients with substance abuse had medical issues that could be
associated with ethanol use/abuse, but this was not noted or documented.
Pain assessments, interventions and outcomes were generally well documented.
However, they were recorded in several different places in the chart, so
sometimes it was difficult to follow progression of a specific pain incident.
Recommendations:
a) Consider implementing a policy that defines long term diabetic management
through the use of routine Hgb A1C.
b) Eliminate “monthly and annual objectives” for the number of bowel
movements for patients and establish a more practical and functional
standard for monitoring that provides accurate and immediate alert if
problems arise.
c) Review default entries of “deferred” to determine if they are being
inappropriately utilized. It may be advisable to not have a default entry if this
leads to incomplete follow-up.
d) Establish procedures for refusal of use of CPAP machines for patients
diagnosed with sleep apnea.
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e) Clients involved in incidents (patient-patient assaults) should be followed with
assessments for pain.
f) Review medication management of patients with hypertension to assure best
practice utilization.
6. Utilization Management –
Findings: UR minutes reflected good quality initiatives and tracking of
information. Many monitors could be followed over a couple of years, with
improved compliance being shown in response to the initiative, and with
subsequent raising of the threshold for continued improvement. Consistent with
surveyors’ observations on the units, there was low compliance with physician
signature on verbal orders, and not much improvement has been shown over a
period of time on this indicator.
NWRH APS data on unauthorized days was very inconsistent with other facilities
(high), but UR staff indicated that they felt this was due to other facilities skewing
their data rather than reflecting a true comparative study. As in other facilities,
APS was reported to be extremely labor intensive without much benefit derived.
UR staff stated that 23-hour observation patients are not reviewed through
utilization management.
Recommendations:
Consider a method for utilization review of 23-hour observation patients.
7. Quality Initiatives –
Findings: It was difficult to track coordination and executive oversight of quality
initiatives through different committees and up through management. It was
noted that the Quality Manager does not attend the Risk Management
Committee, the Patient Assessment and Care Function Team, Ethics Committee,
P&T or the Discipline Chief Meetings. Mention of QI reports and initiatives, as
well as follow-through of issues identified, were very brief in the executive
minutes.
Organization and execution of projects also seemed too weak, and did not
always follow established QI procedures. For example, on FOCUS-PDCA
projects, the “plan” and the “goal” for the project were listed as the same. One PI
project was to decrease the serious injury and death rate by 50%, a goal that the
surveyors were informed was mandated by the central office. The facility
identified three areas to focus on that would contribute to meeting this goal:
reduction of falls, addressing aggressive behavior, and obtaining accurate
information on patient transfers. In practice, each area is so different and
complex it deserves a separate FOCUS-PDCA plan. Lumping them into one
muddies the process and makes a positive outcome more difficult to obtain.
Another project identified as treatment planning addressed recidivism, substance
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abuse assessment, and increased attendance at treatment teams, again,
showing lack of standard QI structure, organization, and focus.
The Director of Quality Management has only been in his position for
approximately one year and has a limited background in mental health, which
may be a contributing factor to the weak program. His immediate supervisor, the
Director of Regulatory Compliance and Training, was not available at the time of
the site visit for interview or comment.
Recommendations:
Review Quality Improvement representation on key committees and teams or
attendance at the meetings to maximize inclusion of performance improvement
activities. Review QI/PI process and procedures to make it more functional,
useful, and consistent with Quality Management Practices.
8. Treatment Plan/Team –
Findings: Treatment teams were attended on most units. On unit 408,
treatment team was conducted by two psychiatrists, with coverage provided for
one other who was on vacation. All patients were reviewed, some briefly and
others in more detail. All staff seemed to know the patients well; a notebook of
patients’ pictures was available if needed. One comprehensive treatment plan
was completed with projection onto a screen and multidisciplinary input occurring
in real time. Notably, no patients attended the treatment team.
On Unit 406, treatment team was informative and patients were encouraged to
actively participate. Patients interviewed were well informed.
Generally, treatment plans were found to be thorough and complete. Groups did
seem to match treatment plan goals. On a few of the DD Treatment Plans it was
noted that target dates had expired, or that they had been extended as many as
two times. There was no evidence, as required by ICF/MR standards, that there
was change made in methodology of obtaining the goal or justification why the
extension was necessary.
Also noted in a DD treatment plan was the statement that a certain patient did
not need a behavior support plan. Behavioral support plans are necessary for
individuals on psychotropic medications to address specific behaviors, and this
patient had been on psychotropic medication for years. Behavioral support plans
that were indicated as a need in treatment plans were not completed in a timely
manner.
Recommendations:
a) Treatment teams should not be held without access to patient charts.
Patients should always be encouraged to attend and participate in the team
meetings.
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b) When target dates for goals are extended for unattained or incomplete goals,
documentation should reflect a change in methodology, techniques, or
interventions that will assist the patient in reaching these goals. The record
should also reflect reasons why goals were not attained.
c) All DD patients on psychotropic medications to address behaviors should also
have a behavioral support plan. When recommendations are made to
develop one, timely completion should be monitored.
9. Patient Rights –
Findings:
Procedure on the admission unit involved the typical search and confiscation of
contraband. After this was done, the staff member retreated behind a glass
window for the patient interview process. This seemed unnecessary, impersonal,
and contradictory to a recovery model.
Advance Directive Forms do not address a Mental Health Advanced Directive.
There was inconsistency noted in the DD charts on whether the individual had
the capacity to give informed consent. For example, the chart would indicate the
person was unable to make choices or consent, but the same chart reflected the
patient’s ability to make choices by turning their head. This may indicate a need
for an assessment and documentation of the level of consent or choices the
patient can make to avoid seemingly contradictory statements.
All restrictions on personal property, which includes hygiene items, must have
the restriction addressed in the treatment plan, approved by
client/family/guardian and the human rights committee. The treatment plan also
must indicate a plan to reduce the need for the restriction. This was not evident
in one chart.
The requirement for DD patients of annual updates for medication consents
appeared to be met, however, some consents appeared rather methodical rather
than relating to actual clinical care.
There is not a filled Patient Advocate position at this facility, but there is a Peer
Specialist whose role is to support the recovery of patients by encouraging their
participation in treatment both while in the hospital and by following their
discharge plans. It was commented that staff training on the “Recovery Model”
would be beneficial to further support this.
Recommendations:
a) Patients treatment regimens should not be changed without a physician’s
order, and denial of access to treatment should not be used as a
consequence for undesirable behavior.
b) Review current policy and procedure for Advanced Mental Health Directives,
HIV testing, and restrictions on patient belongings, establishing or enforcing
compliance with standards and regulations. Also suggest clarifying
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documentation and policy on the ability to indicate choice vs. level of capacity
to give consent.
c) Provide staff training on the “Recovery Model,” and examine current practices
from this perspective.
d) Assure that there is consistency in the consent process when family or
guardian is the one giving consent to make sure they are contacted for all
consents. If attempts to reach the family or guardian are made and are
unsuccessful, this should be documented.
10. Staffing and staff morale –
Findings: Neither the Nurse Executive nor Human Resources were able to
produce staffing data, including vacancy or turnover rates. The Nurse Executive
stated he believed the nursing vacancy rate to be “about 50%”. Consistent with
other facilities, the perception is that turnover is seen mostly with new hires. As
in the other facilities, there are a good number of long term employees nearing
retirement, intensifying the staffing shortage situation. Although there was a
realization of this upcoming problem, it appeared not much was being done in
anticipation of it. There seemed to be more stability in upper management, with
fewer vacant positions than in other facilities visited. Although staff shortages
were not readily apparent on the units visited and milieus were generally under
control, surveyors experienced some problems in having staff and/or
management available due to their being so involved in patient care activities or
covering for others.
Call-ins were a consistent problem, and a system of mandatory “holdovers” is in
place that does not allow staff members to leave until a replacement can be
found. As positive reinforcement for reducing holdovers, nursing has instituted a
“unit of the month” highlighting the unit with the least call-ins.
Overall, morale appeared to be good, and staffing issues did not come up as
frequently as in the other facilities when staff members were interviewed.
Comments instead included needs for computer/technology upgrades, improved
communication, staff training, and enhanced programming for patients.
The facility had a foster grandparent/senior companion program for the DD
population that provided for emotional support and social interaction with the
clients. Care should be taken to assure that staff members are also present in
the area with these individuals to intervene and assure behavioral plans are
implemented. On two occasions, the surveyor noted the grandparent in rooms
with clients and no staff member present. During these observations a client was
exhibiting a behavior addressed on his behavioral support plan.
During the HR interview (the HR Director position is vacant), it was determined
that clinical or discipline managers performed their own reference checks for new
hires. In consideration of the shortages experienced in clinical staff and their first
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priority being patient care, this seemed to be an inefficient use of their time and
perhaps better performed by Human Resource professionals.
In the review of employee file, it was noted that a nursing license that expired in
January was not verified for renewal until March.
Recommendations:
a) As in other facilities, immediate measures to address acute staffing shortages
need to be taken in light of pending retirement of long term employees. This
includes recruitment issues such as examination of salaries and benefits, and
retention issues such as training and qualifications of staff members.
Utilization of measures such as agency staffing and mandatory holdovers
must be seen as short term only, as they actually contribute to destabilization
of staff, lower quality of care, and create additional turnover from staff
dissatisfaction.
b) Monitor the foster grandparent/senior companion program to assure that it is
being used appropriately and not in place of staff.
c) Review procedure of clinical staff members performing HR functions such as
reference checks. Non-clinical departments should act as support
departments to clinical care personnel, especially in light of the shortages and
multiple demands clinicians already face.
d) Nursing licenses and their verifications must be kept current.
11. Training/Staff Development –
Findings: The Director of Training and the primary trainer for MANDT were not at
the facility at the time of the survey, and a substitute who was knowledgeable
about these processes was not available. MANDT training was reported to be
on schedule, however, data or reports supporting this claim were not made
available.
12. Safety/Environment of CareFindings: The facility is located on a large campus, with a mixture of occupied
and empty buildings. Some treatment buildings were grouped while others were
spaced apart. Security fencing around units was aesthetically pleasing rod iron,
rather than institutional chain-link. Grounds were impressively well maintained
and groomed.
The interiors of the buildings were clean, but not as well maintained as the
exterior. Physical repairs were needed on several units. There were a mixture of
beds observed in patient rooms, including metal, wooden and the typical hospital
bed which can be adjusted for height and angle. Hospital beds can be
dangerous, as they can be raised to upright positions to present a suicide risk by
hanging. Several other suicide risks were noted including doorknobs and
exposed hinges in patient rooms and baths, bathroom grab bars and plumbing
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fixtures and window screens in patient rooms with mesh. Patients were allowed
shoelaces and belts. There were some safety inconsistencies noted: locked
trash cans which prevented removal of plastic bags were located just feet from
other trash cans with removable liners and plastic shower curtains in patient
showers. Patient phones with short non-removable cords were across the room
from a “staff telephone” with long removable cords and wires. Other facilities
visited had already removed closet doors in patient rooms, recognizing the risk
that these present. Louvered closet doors with doorknobs and hinges were
observed in many patient rooms. Even with the retained closets, rooms were still
observed to be cluttered.
No doors that were supposed to be locked were found unlocked, the first facility
where this was experienced.
The facility is to be commended for being a non-smoking hospital. Staff in the
23-hour observation unit stated that this actually helped them control
malingering.
Recommendations:
Conduct an internal suicide risk assessment to identify the greatest safety
hazards and implement a schedule of modifications to reduce these threats.
Interim safety measures should be implemented until the modifications are
complete, including increased observation levels and/or limited access to areas
where these risk factors are present. Evaluate need, location and risks of
hospital-type adjustable beds on units.
13. Risk Management –
Findings: Many doors which led onto units were solid with no windows, so the
ability to see and assess who or what was happening on the other side was not
possible before opening the door.
On the DD unit, there seems to be a number of both “unknown” or “unobserved”
incidents and client-to-client incidents. Documentation should include actions
taken to deescalate and prevent further incidents, for example separating the
clients involved, and/or clients being placed on a higher level of observation.
These actions or similar actions should take place immediately, and not wait until
an investigation is complete. Meanwhile, the incidents can continue to be
investigated for elements to prevent future similar occurrences.
It was reported that there was not a designated “Risk Manager” at the facility, but
rather a staff member assigned to gather and log information. As a result, there
is an identified weakness in trending and thorough follow-up of reports. Review
of minutes and Critical Incident Reports revealed possible lost opportunities for
improvement that may prevent similar incidents in the future.
Recommendations:
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Consider filling the vacant position of Risk Manager. Improve examination of
data on individual incidents as well as trending. Include Quality on Risk
Management Committee to use incident monitoring as opportunities for
improvement and risk reduction.
14. Nursing Practice –
Findings: No expired medications were found in any of the medication rooms.
Recommendations:
Review all medication rooms to assure that stop dates are not exceeded.
Review the practice of look-alike, sound-alike medications being stored together
to eliminate potential for mix-up.
SWRH –THOMASVILLE
1. Chart Organization and Content –
Findings: Charts were generally in good order. Long term charts were
understandably thick, but had appropriate content and were organized. Forensic
evaluations were kept separate and findings were not always evident in chart
documentation.
Recommendations:
Results of forensic evaluations should be included in the chart.
2. Programming –
Findings: Patient inactivity was observed on the units, sometimes inconsistent
with posted schedules. Programming for patients not able to attend the
treatment mall or off-unit activities was light, and it appeared that many patients
remained on the unit in fairly cramped quarters. Clear criteria for allowing
patients to attend off unit programming was not available, and it was stated it was
a clinical decision of the treatment team.
Off unit programming offered many groups and activities. The Serenity Room
was a creative approach to reducing patient stressors.
Recommendations:
Make adequate programming available for patients who are not allowed to leave
the units, and then assure that the treatment schedules are followed.
3. Physician documentation –
Findings: Physician notes for DD patients on Rosehaven and 501/510 appeared
complete. Medication rationale and effects were documented, abnormal labs
and other diagnostics were quickly followed up on. Annual and quarterly
updates were present and complete. Results of interventions or failure of
interventions were well documented.
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On the Mental Health Units, admission dictations and annual updates were well
documented. Telephone orders were occasionally not co-signed by the
physician, and some were signed late. One seclusion and restraint order was
signed outside the one hour window. Medication changes and responses were
well documented in the chart; however, use of polypharmacy was not always well
supported in notes. Progress notes were acceptable in terms of frequency, but
were somewhat limited in content. With the adequate physician staffing on these
units, notes would be expected to be more complete. Aggressive behavior
documented in nursing notes was not always referenced or discussed in
physician notes.
Recommendations:
An organized effort to sign telephone and verbal orders may be indicated.
Physician notes should be complete to include discussion of polypharmacy,
patient behavior, and treatment regimens.
4. Seclusion and Restraint –
Findings: Seclusion and Restraint utilization is commendably low. No restraint
beds were observed in any seclusion room. Staff stated that patient beds were
used when restraint was utilized, however it was very infrequent.
The facility stated that they documented manual holds as restraints, and some
forms indicating this were found, but not consistently.
Debriefings of seclusion and restraint episodes were not filed in the chart, but
kept separate. The patient advocate meets with all patients following episodes of
seclusion and restraint, and the episodes are also reviewed by the ethics
committee.
Recommendations:
Review the use of patient beds for restraint from both a safety perspective and
from a recovery model perspective, considering the effects of a patient being
restrained in their own bed.
Examine the definition and application of manual holds to assure compliance with
standards.
5. Medical Management –
Findings: The AMH unit 310 utilized a Team Nurse concept for care delivery.
Each client was assigned an admission pair consisting of an RN and a physician
who worked with them directly throughout their hospitalization. The RN in this
pair had this as her primary role, and had a list of responsibilities assigned to
him/her, including developing and updating the treatment plan, coordinating and
attending treatment team, communicating with the charge and medication nurse
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regarding his/her patient, educating patient and family on treatment and
medications, review of 3-11 and 11-7 reports, and completing chart
documentation including progress notes, quarterly and annual assessments,
consent forms, and legal papers. The concept was implemented to improve
continuity of care and communication with all disciplines. The team also included
a social worker. This concept seems to work very well for both the patient and
staff.
Care of both the diabetic and hypertensive patient seemed relatively good. Hgb
A1Cs to evaluate long term management of diabetes were seen on some
patients with very good results.
Histories were lacking in substance abusing patients in regards to last use,
blackouts, seizures and DTs, and medical issues related to past or present drug
use. Differentiation should be made between substance use vs. abuse vs.
dependence. An up to date detoxification protocol, such as a CIWA scale, was
absent. Phenobarbitol was currently being used as drug of choice for
detoxification, which is outdated.
Patients in Rosehaven and 501/510 generally had a detailed plan of care that
seemed well implemented. Some had an array of complex medical and
psychiatric issues that appeared to be more than adequately assessed and
treated. Pharmacy regularly reviewed polypharmacy. Some laboratory tests
were not followed up on.
Recommendations:
a) Substance abuse assessments should include history of black outs, seizures,
DTs, past use, last use, and medical issues related to present or past use.
Replace phenobarbital with Ativan as the drug of choice for detoxification.
Adopt a detoxification protocol such as the CIWA scale. Diagnosis should
reflect a differentiation between use/abuse/dependence.
b) Hgb A1Cs should be a standard component of long term management of
diabetes.
c) It is recommended that patients who are hypertensive be placed on ACE
inhibitors, especially if they are diabetic.
6. Utilization Management –
Findings: As in the all other facilities, APS was identified as very labor intensive
with limited use. Staff stated that at least now many of the problems of the
system have been rectified and at least the reports are accurate.
Though typically a community-based service, a crisis unit is operated by the
hospital because of unavailability elsewhere. This was recently moved back on
campus. The UR department does not track or review admissions and
discharges from either this or the 23-hour observation unit to assure that services
are delivered in the appropriate setting.
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Staff members stated that patients can stay in the 23-hour observation unit up to
48 hours. This conflicts with hospital policy indicating that admission to inpatient
would occur if the patient “has not stabilized within 23 hours” in that level of care.
Recommendations:
a) A clinical quality review should occur to ensure appropriateness of
admissions to the crisis unit vs. 23-hr observation unit vs. inpatient.
b) Review practice of keeping patients in 23-hour observation beyond 23 hours,
and at the very least adjust hospital policy or practice so that they are in
compliance.
7. Quality Initiatives –
Findings: The Quality Council is part of the Leadership Team, which indicates
strong administrative support for quality initiatives. The agenda for Quality
Council is comprehensive, and includes such topics as client satisfaction survey
results, HR data including turnover and vacancy rates, Risk Management data,
staff development information and typical quality agenda items such as PI Teams
and FMEA reports.
Some quality goals such as reducing critical incidents and patient injuries reflect
total numbers only and are not expressed as relative to census or volume,
therefore decreasing trends may not accurately represent decreasing incidence if
the hospital is downsizing and closing units.
Recommendations:
When tracking information that may be impacted by census or volume of
patients, report numbers in relation to that number to accurately reflect changes.
8. Treatment Plan/Treatment Team –
Findings: Several treatment teams were attended on the Mental Health and
Forensic units. They were well organized and relaxed. All members of the
treatment team were active in the treatment planning process. Patients were
encouraged to participate. Patients seem to know their physician and clinical
staff involved in their treatment, and indicated that they felt cared for and safe.
Notes were written either during or immediately following the patient interview.
DD patients had Individual Service Plans and Behavior Management Plans in
charts and these were completed.
9. Patient Rights –
Findings: The patient advocate, though new in his role, reflects the proactive
attitude of the facility. He responds to patient/family complaints, leads recovery
groups, is active in promoting the recovery model with staff and meets
individually with all patients following seclusion or restraint episodes. He has
developed an institutional advanced mental health directive for patients which he
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completes with them prior to discharge when they have stabilized and which can
be used if they are ever readmitted. These directives include physician choice,
medication choice, and preferences regarding emergency interventions. It was
noted that these emergency interventions only include seclusion, restraint, or
medication. All seclusion and restraint episodes are also reviewed by the Ethics
Committee.
Informed consents for medications allowed multiple medications on one sheet.
Recommendations:
On the institutional mental health advanced directive, include something other
than seclusion, restraint, or medication as a choice for an emergency
intervention, or it may be helpful to include an additional question that addresses
interventions that could be performed before the use of seclusion, restraint or
medication.
10. Staffing and staff morale –
Findings: Though facing many of the challenges the other facilities face in terms
of salaries, retention and turnover, SWSH seems to have found some measure
of success in staffing the facility. Commendably, no agency staff is used,
turnover is very low, and vacancy rates are much lower than other facilities
surveyed. Morale is generally very good, with management identifying some
issues with transferred Bainbridge employees and those facing reassignment
with the continued closing of DD beds. The facility seems to be proactive and
sensitive to these staffing needs, which contributes to its success. It was evident
throughout the survey that good communication, teamwork, true patient
compassion, pride and leadership all contribute to staffing successes. The
facility and staff also seem to be well connected to the community, promoting
relationships that assist in recruitment. Linkages exist with Nursing schools, with
students completing their psychiatry rotations at SWSH. Internally, staff is
supported as well, contributing to retention. Mentoring programs are set up for
new employees. An incentive exists to encourage continued education, and
multiple examples of professional advancement were seen within the
organization, including certifications of Psychiatry and Forensic Technicians,
advancements from CNA to LPN to RN, and even to Nurse Practitioner, all with
employer support and encouragement. A peer program exists for employees
involved in patient assault incidents or falsely accused by patients to help support
them with personal issues that remain from those events.
When downsizing was indicated because of budget reductions, both
management and staff reported that clinical or direct care staff was not impacted.
Administration chose to cut middle management or administrative positions. This
not only seems operationally appropriate, but was referenced by many
employees as positively affecting morale and reflecting an organizational
commitment to patient care.
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Physicians also are well staffed with competently trained and board-certified
physicians performing in their specialty fields. The physician treating the DD
clients knows his patients extremely well, and has contributed to these very
medically fragile patients living past their life expectancy.
Pharmacy is well staffed with four pharmacists, two of whom are nearing
retirement. They state that salary scales may make it difficult to recruit
replacements, as pharmacists are not able to make over $100,000 in some
settings. The pharmacists are involved in Performance Improvement activities,
and monitor PRN and polypharmacy utilization.
A foster grandparent program exists to provide 1:1 attention and emotional
support for DD patients. This was noted to be implemented and utilized
appropriately. Reference checks were performed and their presence with
patients did not replace staff.
The admission unit was not staffed with an RN, as noted in a previous facility.
This presents a situation where a patient that has not been assessed is not under
medical supervision while he awaits evaluation. Also, for some shifts in
Rosehaven, only one RN is on duty for the entire building.
A team nurse concept has been implemented and seems to work nicely.
Recommendations:
a) Continue efforts of recruitment and retention, with emphasis on areas facing
shortages because of retirement and non-competitive salaries to attract
replacements.
b) Evaluate need for RN in admission unit and for adequate coverage in
Rosehaven.
11. Training/Staff Development –
Findings: Staff members stated that SWSH was one of the first to implement
MANDT training, and reported that they are at 100% compliance with advanced
training for all employees.
As mentioned in the previous section, continuing education and professional
advancement is not only encouraged, but supported.
Competency files were reviewed by two surveyors, and were in order.
12. Safety/Environment of CareFindings: SWSH is located on an attractive and well maintained campus. The
Treatment Mall located in the Administration Building and Rosehaven provide
excellent environments for treatment. They are open, spacious, warm and light,
providing a pleasing atmosphere for care and recovery. The Rosehaven building
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was immaculately clean with no odor even on the skilled nursing facility. The
Mental Health and Forensic buildings, 310 and 414, were not as architecturally
outstanding, with limited space resulting in a somewhat crowded and closed in
feeling. However, the buildings were well maintained and clean. The facility has
also identified that the limited physical space can cause patient management
problems, and have taken steps to address this issue. For example, on the
acute mental health unit, a number of private rooms are available for patients
who are potentially assaultive or do well with more personal space. They have
also created a separate unit identified as “secure unit” in the Mental Health
Building that can hold up to 6 patients who are high management or could be
dangerous to other patients. This unit is rather stark and bare, but seems to
serve its purpose well.
Suicide risks identified on the units included interior patient room doorknobs that
could support weight. Although patient telephones were modified with short nonremovable cords, other conventional telephones were still observed on the units
in patient care areas that had long removable cords. Bathroom modifications
had occurred with suicide proof grab bars and showerheads installed, but other
plumbing hazards remained, such as the on-off knobs in the showers. Plastic
bags were also noted in multiple patient areas, including some in areas where
staff did not continually supervise. Shoelaces and belts were limited for patients
on suicide precautions, however staff did report that other patients on the unit
were allowed these items and it was difficult to monitor.
There was a mixture of beds in the facility, including hospital beds which can be
raised and present a suicide risk. Beds and other bedroom furniture are also
movable and with patient room doors opening “in,” could be used to barricade
and prevent entry.
Most outdoor recreation areas were aesthetically pleasing without chain-link
fences or obtrusive barriers. However, the brick patio for the mental health unit
does not appear secure and would allow relatively easy scaling and elopement
opportunity. This has been documented in the past, and the wall has been
equipped with an alarm system to alert staff to patients attempting to jump over.
The Safety Committee had excellent clinical representation, and with a combined
environment of care and clinical focus, allowed complete reporting and action to
safety issues or incidents.
Recommendations:
a) Continue to conduct suicide risk assessments to provide a safe environment
for patients. Renew efforts to remove plastic bags from patient areas.
b) Evaluate risks associated with movable furniture in rooms.
c) Reduce elopement risk from bricked patio.
13. Risk Management –
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Findings: The Risk Management Department was recently supplemented
allowing more staff to complete investigations, reports and trending. The
meeting minutes show good clinical and management representation, and also
reflect review of individual incidents. Efforts to improve trending and
identification of commonalties are underway. Risk Management staff also
expressed their goal of a more thorough discussion of incidents in meetings.
Recommendations:
Continue efforts of quality improvement and risk reduction by closer examination
of individual incidents, and trending analysis of collective incidents.
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SYSTEM REPORT
MCG would like to thank the Division for the opportunity to be a part of the
performance improvement process for Georgia’s mental health delivery system.
This work would also not have been possible without the effort, time and
cooperation of management and staff at each of the facilities, and we would also
like to express our appreciation to them for their support and contributions in this
process. As we completed each audit and reported out our findings to faculty,
and staff, we were impressed by their motivation for change and desire for quality
improvements.
Additionally, Division leadership requested that the individual reports of each
facility be explicit and specific. Their “tell it like it is” approach was consistent
with their response to the recommendations and their commitment to improve the
hospital system. In this regard, this responsibility throughout the audit process
itself contributed to an ongoing quality improvement process wherein some
recommendations were implemented during the audit process. This local and
central responsiveness during this audit was commendable.
System Strengths:
In general, the core staff at the facility level are committed to their jobs, and have
continued to show compassionate care and dedication to their jobs in the face of
staffing shortages, patient care challenges and, recently, exposure in the media.
Many of these employees have worked in the state system for 20+ years, some
as many as 30. Their experience and stability have enabled some of the
hospitals to continue to function in the face of significant adversity. They also
provide a core on which a better system can be built, and reflect an attitude that
is receptive to positive change. For the most part, an optimistic morale seems to
be sustained despite continued challenges.
In addition to the strengths found in this long term employee base, other positive
aspects were noted during the audit process. Probably the most impressive was
the medical care provided to the developmentally disabled population. Severely
medically challenged, these patients receive care that has allowed many of them
to live far past their projected life expectancy. The complete absence or very low
incidence of decubitus ulcers in the bed ridden portion of this population was very
commendable. This is also significant as skin integrity is often used as an
indicator of general health care and attention. In all the facilities, the
environments of care designated as SNFs, or skilled nursing facilities, could be
called pristine.
Constructive efforts that have had positive outcomes were also noted in the
review of the state system. This includes the elimination of smoking in many of
the facilities, a health benefit which was also referenced by staff to assist in
patient management as it eliminated potential fighting, “under the table” trading,
and patient demands for smoke breaks. The institution of the MANDT program
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to address the management of aggressive patients played a role in the reduction
of the use of seclusion and restraint, in compliance with a national initiative in
mental health care. The state system has been supportive of the use of new
psychotropic medications for best practice treatment of serious mental illness.
Generally, appropriate use of these medications in terms of indications and
dosages was noted during the audit.
Although all of the facilities are physically showing their age and environmentally
present safety concerns, most hospitals have identified the hazards and have
taken steps to address many of them, limited mostly by funding and the
prohibitive costs of some revisions and modifications.
By and large, treatment teams operated well with well documented and
productive treatment plans. Facilities were proactive in opening programs that
would decrease re-admissions, such as 23-hour beds and crisis programs,
despite the fact that the hospitals receive no reimbursement for these services
because they are outpatient programs. All facilities have tried to enhance
programming and encourage treatment choice by patients through the creation of
Treatment Malls. Some hospitals have established positions of patient
advocates and/or peer specialists, and show interest and intent in moving toward
the recovery model.
Collectively, these represent considerable strategic strengths and personal
resources upon which to build further. As noted, several initiatives for quality
improvement have already begun on a system level. In addition to contracting
with MCG to perform facility audits, the Division is utilizing other outside
consultants to examine procedures and performance. Reports are immediately
used to implement correction plans and conduct change. The Division is also
meeting with advocacy groups and consumers to obtain direct feedback
regarding the delivery of care and personal experience in the mental health
system. This involvement of advocacy groups and consumers is a key step in
moving forward. A Gubernatorial Task Force has been formed to study the
system and provide recommendations. The Department of Justice investigation
will also yield a report to which the Division will respond. The media also
contributed to this positive momentum by providing ongoing coverage and to
raise public awareness about mental health.
Findings and Recommendations:
The following findings and recommendations for system-wide implementation
that are presented by MCG Department of Psychiatry and Health Behavior are
those that were consistently identified as problematic in all or most facilities, are
systems where a statewide plan would create efficiencies, improve overall patient
care, and/or maximize the benefits of a multi-hospital system, or are issues that
must be addressed at the state level. These findings are consistent with
performance improvement recommendations of regulatory agencies typically
involved in the review of care in healthcare organizations, such as CMS and Joint
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Commission. These findings and associated recommendations are detailed
below. Additionally, a selected bibliography of key publications and mental
health policy documents is included in support of these recommendations.
1. System Resources and UtilizationThe consensus of all team members was that staffing resources, mix and
utilization were the most urgent issues that must be addressed by the Georgia
State System. Although the severity of the problem differed between individual
facilities, without exception this was the most consistent and significant challenge
at each facility. Staffing shortages were noted in almost every discipline, and
employees consistently identified this as the major problem and top priority for
attention and change. Some of the specific consequences of depleted staff are
outlined below.
Consequences of low staffing levels……
Incomplete initial assessments
Diminished capacity to meet with families
Incomplete or superficial documentation
Reduced oversight of patients
Increased number of verbal orders
Reduced unit programming
Incomplete discharge planning
Mandatory overtime
Use of management in direct care positions
Which further results in……
Increased risk of suicide, assaultive
behavior, elopement, unexpected
detoxification symptoms and medical
complications because of inadequate risk
analysis
Decreased collateral information gathering,
limited discharge planning, lost
opportunities for family education and
support in the recovery process.
Poor interdisciplinary communication, less
than optimal clinical care
Increased risk of assaultive behaviors,
suicide attempts, elopements, unobserved
or noted deteriorating medical conditions
and de-compensating psychiatric
conditions.
Increased opportunity for errors
Patient boredom, increased aggressive
behavior, exacerbated depressive
symptoms, lost treatment opportunities
Patient relapse, readmission, treatment
failure
Employee burnout, increased turnover,
decreased retention
Decreased supervision of line staff,
management burnout, neglect of
management duties such as quality
improvement activities, risk management,
etc.
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Increased use of agency/locums personnel
Insufficient individual therapy time
Incomplete charting
Accelerated recruitment/hiring processes
Increased turnover, decreased retention
Increased time spent on staffing and scheduling to
obtain necessary coverage for patient care
Provision of care by temporary staff not
fully trained and not invested in long term
success of the program, staff frustration
with unstable workforce resulting in more
turnover, increased employee costs
Lost opportunity for patient education,
treatment and evaluation of patient
response to treatment,
Patient rights violations with lapses in
informed consent documentation.
Standard and regulatory deficiencies.
Lack of follow-up on diagnostic testing.
Lowered standards for hiring personnel,
shortened orientation and training process,
decreased retention
Wasted recruitment efforts, wasted training
and orientation efforts, increased labor
costs, diminished community image
Equivalent loss of time and resources
spent on employee supervision, direct
patient care activities, other management
duties
Staffing levels, mix and competencies impact multiple aspects of patient care and
operations, and other identified quality issues either exist or are exacerbated by
deficiencies in this area.
Vacancy rates can be impacted by many factors, including salaries, recruitment
efforts, retention practices, orientation and training, staff composition and
organizational structure. All of these need to be addressed in order to reach the
most effective level of staffing in the state facilities.
RECOMMENDATION 1.1: A comprehensive salary survey should be
conducted to determine current salary scales for all professional staff
members.
The salaries for the professional staff of the facility, namely nursing, pharmacy
and physicians lag behind, and sometimes substantially behind, industry
standard. Because of the diversity of the hospital system, this presents a
different kind of challenge for each facility, however the effects of submarket
salary levels are the same. Hospitals in more urban areas with multiple
competing job opportunities, such as Atlanta and Augusta, lose prospective
employees to other hospitals offering significantly higher salaries. Hospitals in
more rural areas such as Milledgeville, Thomasville and Rome, have difficulty
attracting professionals to relocate to the area.
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RECOMMENDATION 1.2: Restructure salaries to be in the 70th – 80th
percentile level for regional market scales.
National market shortages of most health care professionals, coupled with the
current suffering reputation of the Georgia State Hospital system, will require
DHR to offer salaries at the top end of the scales to attract high quality
professional staff to fill current and anticipated openings.
A cost analysis of current expenses associated with agency utilization, overtime
and turnover may show a less than expected financial impact if agency and
overtime can be eliminated, and turnover reduced. Although raising salaries
alone will not solve the staffing crisis, neglecting salary levels or insufficiently
addressing them will significantly hinder the resolution of the critical staffing
situation.
RECOMMENDATION1.3: Collaborate with Georgia’s universities and
training programs, as a resource for current and future staffing needs.
Most facilities were active in recruitment efforts which included job fairs and
advertisement of job openings. However, in a market where there is a shortage
of healthcare professionals, recruitment needs to be more aggressive and
proactive. Involvement in training programs such as nursing schools, medical
schools, residency programs, and pharmacy internships allow opportunities to
capture prospective employees before they graduate, and then offer enticements
such as repayment of school loans in exchange for commitments to work in the
state system. State university collaborations are used in many other states as a
valuable approach to enhancing care and resources within the public mental
health system.
RECOMMENDATION 1.4: The Division should be supportive of professional
networking to provide exposure, represent system and individual facilities,
and promote recruitment activities.
Professional networking provides exposure and promotes job opportunities within
the state system. This should be done on a national, state, and local level. On
the hospital level, managers should be encouraged to participate in state and
community organizations and events as representatives of their own and other
state hospitals. This not only supports recruitment activities, but has the
additional benefit of providing professional development and training, promoting
increased competencies, job satisfaction and retention. This approach, fostered
over time, also builds greater professional alliance throughout the system.
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RECOMMENDATION 1.5: The Division should employ their own
professional recruiters to attend national conventions and meetings to
seek out and attract professionals whose interests include inpatient
treatment.
Some positions, namely medical staff and pharmacists, will require the efforts of
full time professional staff for recruitment. This will not only assist in providing
sufficient numbers of staff to fill current and anticipated openings, but will assure
the recruitment of highly qualified personnel who are the “best fit” for individual
positions. This will stabilize and improve the workforce considerably.
RECOMMENDATION 1.6: Retention and turnover rates should be tracked
and monitored by hospital, by discipline, and by unit, with both local and
state interventions for identified problem areas.
All recruitment efforts are wasted without effective retention. Effective retention
begins with awareness and knowledge of who is leaving and why. Knowledge of
why people are leaving will help in developing an effective retention plan.
RECOMMENDATION 1.7: Effectively administer employee surveys to
determine key points of job “dissatisfaction,” and then employ successful
interventions at both the local and state level to improve retention rates.
Employee satisfaction and exit surveys are being conducted, but results are not
fully utilized. Exit surveys are often are given to terminated employees as well as
those who have resigned voluntarily. This can skew data and make it more
difficult for appropriate administrative response for improved retention.
RECOMMENDATION 1.8: The Division should create a positive culture and
an affirmative work environment through supportive supervision,
constructive mentoring, and a collaborative work relationship with hospital
level administrative and midlevel managers.
Studies have shown that employee’s direct supervisors can have the most
impact on job satisfaction and retention. Employees must feel as if their
supervisors are receptive to their input and value their opinion, and are sensitive
to their needs. A collaborative working relationship is most effective for not only
employee retention, but also optimal organizational functioning. For lower level
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employees, much of this effort must occur at the hospital level by mid level and
department managers. However, this can be greatly impacted by upper
management, creating a trickle down effect, when a supportive and affirmative
work environment is created with positive mentoring and supervisory techniques.
This is also tied to creating a “culture of quality” (see recommendation 9.2).
RECOMMENDATION 1.9: Invest in current employees by supporting
professional growth, education and career advancement.
Opportunities for advancement have also been shown to be an effective retention
strategy. Career ladders can be established for most positions that create
incentives for improved skill levels, increased responsibilities, and higher
education. Support for continued education can be provided through tuition
reimbursement, time off for class attendance, or even provision of classes onsite. Continuing medical education is an important aspect of ongoing staff
development. Regular on-site and system-wide educational opportunities should
be made available through the use of local resources, including universities. This
approach can also foster greater connection with the community.
RECOMMENDATION 1.10: Establish a peer support network for employees
involved in traumatic incidents with available professional help as needed.
Inpatient mental health care constantly presents difficult and demanding work
challenges. Situations can arise daily that can be potentially life-threatening for
both patient and employee. This creates daily a stressful environment for
employees, but especially for those that have already been involved in traumatic
incidents such as assaults, altercations, incidents of injury of death or
unsubstantiated accusations of abuse. The mental health issues of these
employees need to be addressed, providing professional and peer support both
before and after returning to work. This action would also indicate recognition by
management of line staff’s work environment, boosting morale and employee
confidence in administration’s sensitivity to their needs.
RECOMMENDATION 1.11: Conduct a thorough analysis of the salary,
education and training requirements of the Health Service Technician and
make them comparable to the job responsibilities and risk factors
associated with this position.
Patients presenting at state hospitals often have severe mental illness
complicated by multiple co-morbidities. Not only do these present significant
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treatment challenges independently, but when co-occurring make detection and
monitoring of their conditions that much more challenging. Patients are not
always capable of self-reporting symptoms or conditions, and therefore staff must
be keenly aware and skilled at assessing patient status. This heightens the
responsibilities placed on health care professionals for the monitoring of these
patients. Furthermore, unexpected and unanticipated situations can arise where
immediate intervention, either medical or psychiatric, must occur to avoid
escalating problems. It is essential to be able accurately assess and
appropriately react, even if that means simply calling for help, assistance, or
consultation by a colleague, nurse or physician. The Health Service Technician
job classification requires no prior health or mental health experience or
education, yet Health Service Technicians are the primary attendants and care
givers to patients. They are the least trained personnel, but have more patient
contact and patient supervision responsibilities than any other discipline.
Salaries for this position compete with fast food restaurants and housekeeping
personnel. Increasing minimal qualifications for this position, along with adjusting
the salary scale, would significantly impact the quality of this level of staffing, and
greatly impact patient care, treatment outcomes, and risk management.
RECOMMENDATION 1.12: Create a statewide standardized orientation
program complete with extensive classroom training and a period of
shadowing and mentoring on the patient care units before new employees
are assigned a patient care load or allowed to act independently.
For even the experienced health care professional, thorough orientation and
training is necessary before accepting solo responsibility on patient units.
This should not only involve formal classroom training, but shadowing and
mentoring in patient care areas before the new employee performs
independently. Turnover is highest among short-term employees, and adequate
training can help to reduce this phenomenon. The increased cost associated
with longer more intensive orientation and training would most likely be offset by
a decrease in turnover.
RECOMMENDATION 1.13: Provide a stable workforce by allowing creative
and flexible scheduling, incentives for call coverage, and part-time or job
share positions.
Creative and flexible scheduling can sometimes offset lower salaries in
recruitment and retention. Weekend options, 12-hour shifts and part-time
positions, can attract professionals looking for schedules that fit their lifestyle.
Enticing reimbursement for on-call schedules can encourage staff physicians,
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those most familiar with current patients, to provide coverage rather than hiring
residents or outside physicians to provide care.
RECOMMENDATION 1.14: Establish scheduling guidelines with approved
and accepted acuity scales appropriate to patient population and condition
to determine adequate staffing levels.
Utilization of existing staff resources based on acuity and patient mix was not
standardized or well established. Procedures for determining staffing levels
using established guidelines or based upon national standards should be utilized.
Staff scheduling should consider patient population (i.e. adult, adolescent),
census levels, acuity, precaution levels, admission and discharge activity,
adjusting staffing levels accordingly.
RECOMMENDATION 1.15: Examine organizational charts to find
efficiencies and ensure that reductions in overhead and administrative
costs have occurred that correspond with decreasing patient census and
line staff.
On the hospital level, an effective organizational structure can create efficiencies,
best utilize existing resources, and cut salary costs while preserving clinical
quality. It can also maximize the utilization of limited or expensive resources,
such as nursing personnel that require higher salaries and/or are in short supply.
Most facilities have experienced significant downsizing in recent years. This
coupled with the existence of staff that have very long tenures and remain in
positions that are no longer necessary and/or efficient may require administrative
reorganization.
RECOMMENDATION 1.16: Salary scales should support nursing retention
in nursing roles.
Positions which do not require a nursing degree but have higher salaries, such
as program administrators, have attracted RNs out of nursing positions creating
more nursing shortages.
RECOMMENDATION 1.17: Review current numbers of Ph.D. psychologists,
eliminating, reassigning, or restructuring positions for best utilization and
cost effectiveness.
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Psychologists are necessary in the forensic population for court ordered
evaluations and in the DD population for behavior plans, but psychological
testing can be more cost effectively performed in an outpatient
setting, and psychotherapy can be provided by master level therapists.
RECOMMENDATION 1.18: Consider the formation of a case manager
position within the Social Work Department to assist with discharge
planning.
The current role of the master’s prepared Social Workers in the inpatient setting
is mainly discharge planning and placement. Creation of case manager positions
to assist Social Workers could reduce salary costs in this department, or provide
for additional resources without increased salary costs. This could also allow
Social Workers to be utilized for more family work, recovery education, and
therapeutic interventions with patients, such as group or individual therapy. Case
management positions could also provide a career ladder for Health Service
Technicians, a benefit aiding in retention.
RECOMMENDATION 1.19: Examine job responsibilities and task
assignments so that clinical disciplines are supported by non-clinical
disciplines, and not visa-versa, maximizing the time and efforts of those
with patient care responsibilities.
Professionals that provide patient care should be supported by other hospital
staff so that their focus, energy and time are spent on patient care. For example,
Human Resource functions such as reference checks and license verifications
should be performed by Human Resource Personnel. Medical Record functions
such as chart purging and thinning should be performed by Medical Records
personnel. Likewise, scheduling, an extremely time consuming function, should
not be performed by nurse managers. All of these allow more direct patient care
to be provided by nursing, as well as improved supervision of others providing
direct patient care.
RECOMMENDATION 1.20: Examine the prospect of statewide shared call
coverage for Pharmacists.
The possibility of statewide rotation and coverage of pharmacy call could reduce
the frequency of call responsibilities for Pharmacists, reducing after-hour
responsibilities and burden, and increasing job satisfaction.
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RECOMMENDATION 1.21: Create 3 or 4 associate state level Medical
Director positions to focus on key areas system-wide, such as forensics,
medical oversight, risk management, the developmentally disabled
population, child/adolescent treatment, etc.
On the state level, organizational structure should also be one to support
operations of hospitals. One Medical Director tasked with oversight of 7 facilities
does not fully serve the needs of the physicians, patients and staff of each
hospital. Policy design and implementation should not be purely administrative in
nature, but created, supported and implemented by physicians and mental health
professionals.
RECOMMENDATION 1.22: Perform cost-benefit analysis of outsourcing
services on a system-wide basis such as Laboratory and Pharmacy.
Because of the difficulty in recruiting Pharmacists, supporting this function
through contractual arrangement may be advantageous. Having such a large
hospital system can provide negotiation leverage and make outsourcing
financially beneficial. Laboratory tests are another outsourcing opportunity, and
could not only relieve staffing problems, but also reduce the need for expensive
technology and equipment purchases/leases, inspection preparation and fees
and space requirements.
2. Chart content and organization –
Inconsistencies in chart content and organization throughout the system point to
the advantages of having a standard chart and chart order. Creating standard
forms can reduce printing costs through volume production, ensure compliance
with standards and regulations, and create efficiencies by facilitating access and
transfer of information. All of these will ultimately improve patient care.
RECOMMENDATION 2.1: Develop a statewide consistent chart, including
standardized forms, content and organization with central office and
hospital input and approval.
There is a voluminous number of chart forms at each facility. Some are better
than others, and through a statewide project, taking the best and/or best parts of
forms and incorporating into standardized forms would benefit the entire system.
At some facilities, several forms have been combined, making a continuous and
cohesive process, assessment, or treatment record and eliminating excess
paper. Conversely, there are some forms that have been implemented statewide
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that are not user friendly. In the development of forms, it is essential to receive
the input of the professionals that are using them.
RECOMMENDATION 2.2: Assign the monitoring and maintenance of open
and closed charts to Medical Record personnel.
As addressed under staffing, the monitoring of chart content, organization and
associated thinning and purging activities is best addressed by medical record
personnel. The advantages to this are many, including expertise, consistency,
and best use of staff. Medical Record staff members are trained to maintain
records. They have the expertise to recognize what belongs on the chart and
what does not. They are the most familiar with the medical record retention
policy, and can implement it consistently. A consistent problem observed in the
facilities was the use of old forms even though a new form had been created,
sometimes as long as years ago. This was due to a simple error of old forms
being tucked away in drawers or cabinets, and then reappearing and put back
into use. Unit staff members, perhaps new or just unaware of the small changes
or slight differences in the new form, do not recognize the difference and utilize
the old forms. Medical Record personnel would be quicker to identify this issue
on isolated units and correct it because they are monitoring chart content
hospital-wide. When unit staff members are responsible for this function,
turnover only perpetuates the problem, as medical record content is low on the
priority list in training and commitment to memory. Finally, as mentioned earlier,
patient care staff members are freed up to do patient care, rather than
paperwork.
RECOMMENDATION 2.3: Investigate the use of new technologies available
and set a target date for the implementation of a user-friendly, fully
electronic medical record.
Ultimately, moving toward an electronic medical record will improve quality and
coordination of care during hospitalization, but even more importantly, throughout
the continuum. A secure, privacy-protected linkage with community providers’
computerized medical records will allow immediate access to current medications
and pharmacological history upon admission. Discharge summaries and course
of inpatient treatment would be available for outpatient providers for immediate
aftercare treatment. This cost-effective strategy will improve overall patient
outcomes.
As recommended by the 2003 President’s New Freedom Commission on Mental
Health, the electronic record can also incorporate technologies to include clinical
reminders, tools for decision support, clinical practice guidelines, and patient
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safety alert systems such as drug interactions, contraindications and allergies.
This reduces medical errors or adverse incidents or events.
3. Statewide Policy and Procedures –
RECOMMENDATION 3.1: Adherence to a system-wide Policy and
Procedure Manual that has been developed and approved by the Division
and all Hospitals.
Currently, there is neither conformity nor consistency in policy and procedures for
the state system. Manuals differ considerably in volume, content, and
organization. The value of a Master Policy Manual is obvious: continuous
compliance with standards and regulations, and consistent delivery of care.
However, they should exist in terms of a template, with changes, deletions and/or
additions made for individual facilities when their unique functions require
modifications to the procedures. The changes should be made with Central
Office knowledge and approval.
4. Medical Staff Composition, Bylaws, and Rules and Regulations –
RECOMMENDATION 4.1: Medical Staff Bylaws should set standards of
board certifications for the level and type of care provided, including
general, forensic, and child/adolescent credentials, and include provisions
for supervision of residents providing on-call services.
The composition of the medical staff varied significantly between facilities, not
only in number and associated patient care load, but also in credentialing and
specialty areas. This was true for on-call staff, psychiatry staff, and consulting
staff. At a minimum, the Georgia State System for mental health should employ
board-certified physicians for the level and type of care they are providing.
Psychiatrists treating children and adolescents should be board-certified in
Child/Adolescent Psychiatry; those treating forensic patients should be boarded
in Forensics. This is not to say that in some cases, currently employed
physicians who are not boarded do not provide adequate care, but as a
credentialing policy, as reflected in Medical Staff Bylaws, this should be the
standard. Credentialing standards should also address on-call and after hour
provider qualifications, and if residents provide this service, then procedures and
requirements for their supervision should be clearly defined.
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RECOMMENDATION 4.2: Medical staff bylaws and each facility should
support the strategic use of consultants who can provide expert support to
inpatient care.
As has been readily acknowledged earlier in this document, the complexity of
illness and comorbidities in many patients who receive care within the hospitals
is a key consideration. Our earlier recommendation is that the Division recruit
clinicians with speciality and certification (e.g. forensics) which are pertinent to
the needs of this patient population. This effort can be complemented by the
strategic use of local consultants to the hospital. This also has the advantage of
enhancing the communication and connectivity between inpatient and outpatient
providers.
5. Substance Use/ Abuse /Dependency Treatment –
RECOMMENDATION 5.1: Develop a comprehensive program for
drug/alcohol treatment, including the recognition and treatment of medical
complications commonly associated with substance use.
The prevalence of substance abuse as a dual diagnosis or high risk factor in the
forensic and mental health population speaks to the need for development of a
comprehensive defined treatment program for substance use, abuse and
dependency. Treatment should include screening and assessments, withdrawal
risk identification, medical detoxification procedures, drug education and
recovery groups. Programs should address the physical, mental and emotional
components of addiction.
Job classifications, competencies and staffing requirements should be developed
for substance abuse counselors. Policies and procedures need to be written and
implemented for the treatment of substance abuse and chemical dependency.
Physicians and other medical personnel should be trained in risk identification,
detoxification procedures and medical complications associated with the use of
drugs and alcohol.
RECOMMENDATION 5.2: Drug/alcohol treatment should be made available
to all patients, whether they are merely at risk for drug use or experiencing
long-term dependency issues.
The 2003 President’s New Freedom Commission on Mental Health indicated the
need for integrated treatment programs overcoming the traditional separation
between mental health and substance abuse treatment. Instead of patients
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choosing or being assigned a treatment “track” or program focusing on mental
health or substance abuse issues, drug/alcohol treatment is incorporated into all
treatment programs. The long-term treatment success of psychiatric disorders
will be positively affected by the added attention to drug/alcohol issues.
6. Medical management of patients –
It is well documented that persons with mental illness have an increased
prevalence of general medical conditions, including cardiovascular disease,
diabetes, digestive disorders, hypertension, obesity and gastrointestinal
problems. Substance use carries a high risk of serious illness and complications,
including HIV, liver disease, heart disease and diabetes. The institutionalized,
developmentally disabled population contains extremely medically fragile
patients. Those that may not be as critically ill are challenged by a multitude of
complications and long term medical issues that require constant and diligent
care.
Furthermore, mental illness can impair self-care of personal health and
adherence to their prescribed treatment regimens. Psychiatric crises will only
exacerbate these issues, so when patients present for admission, they are likely
to be in compromised health or have deteriorating medical conditions.
The treatment of psychiatric conditions presents health challenges in and of
itself. Medication administration and side effects and complications associated
with the use of psychotropic drugs present medical challenges of their own. So
patients who may have long term, previously stabilized conditions, or may be
completely free of co-morbid conditions can be also expected to have or develop
medical conditions that need attention.
RECOMMENDATION 6.1: Have a sufficient number of general practitioner
physicians, at least one at each site, board-certified in internal or family
medicine, to provide consulting and routine medical care for psychiatric
inpatients. In facilities with both MH and DD populations, one model is to
have psychiatrists as the attending physicians for mental health/forensic
patients and internists or family physicians as the attending physicians for
the developmentally disabled patients, with each acting as consultants for
the alternate population. This provides on-site immediate and consistent
coverage for both psychiatric and medical needs. The number of
physicians still must be sufficient to allow adequate time for both attending
and consulting responsibilities.
The transfer of mental health patients from the Regional Hospitals to medicalsurgical facilities for emergent or specialty care is sometimes difficult and often
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delayed. This only intensifies the need for recognition and management of both
acute and long-term conditions to keep them from escalating into conditions
necessitating transfer. For all of these reasons, having competent medical
personnel as part of the staff of Regional Hospitals therefore is essential. Patient
outcomes will include fewer medical complications, better general health and
wellness and therefore improved response to psychiatric care, more rapid
recovery and decreased length of stay. Patient transfers for emergent and
specialty care will be reduced but not eliminated, so contractual arrangements for
consultative services and formal service agreements with external providers will
still be necessary.
Over the course of the surveys, several general areas emerged as medical
issues that are prevalent in the population and in need of better defined systems
of care. The management of diabetes, hypertension, and medical problems
commonly associated with long term alcohol and substance abuse were among
these. This list is by no means comprehensive, as the incidence of physical comorbidities in this population is quite high.
RECOMMENDATION 6.2: Use affiliation with Georgia’s medical schools
and universities to provide training, education and best practice
management for recognition, early detection, and treatment of medical
conditions.
Some of these problems can be traced to the absence of clinical practice
guidelines, or guidelines that may not be considered best practice. Variations
from known standards of care, variations of care because of lack of standards or
lack of coordinated care not only constitute ineffective treatment environment, but
also create situations of danger for patients. Ensuring that staff are well trained
in the basic recognition and management of medical conditions is an important
task. There should be ongoing educational opportunities that focus on medical
issues relevant to this patient population. State University collaboration as well
as local resources can also assist in this important, ongoing activity.
7. Utilization Management –
Utilization review is a difficult process to evaluate, looking at only hospitalprovided services, since outpatient and community services and the criminal
justice system play such a large role in overall utilization management. Likewise,
data on re-admissions and length of stays are more useful when looked at in the
context of the larger mental health delivery system.
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RECOMMENDATION 7.1: Re-examine utilization management systems for
cost-effectiveness, data relevance, accuracy and usefulness. Do not hold
hospitals accountable for utilization data that is mainly determined or
strongly impacted by external forces beyond their control..
In response to perceived needs in outpatient services that affected their
performance measures, hospitals have established on-site programs that are
typically provided in outpatient settings. This is provided despite the fact that
sometimes there is no reimbursement for these services, as they must be
provided by an outpatient facility to be eligible for funding. Examples of these are
crisis programs, supported residential placement, emergency care and long term
substance abuse programs. Although these services are needed, the provision
of them by the hospitals is complicated.
The facilities reported that the creation of the APS system of utilization
management was supposed to provide data that supported the need of
outpatient programs by identifying the impact on inpatient systems when these
programs did not exist or were poorly delivered. Instead, what was consistently
reported from hospital to hospital was that the result of the implementation of
APS was time-consuming project for which they were held accountable for the
data that was produced. Lengths of stay are out of individual hospital’s control
when it is primarily lack of placement and aftercare keeping patients in the
hospital. UR Managers had difficulty verbalizing how extended length of stays
due to placement issues were distinguished from those that may be treatment
resistant or treatment failures in need of second opinion or consultation. Data
comparisons between facilities were also rendered difficult to evaluate by the fact
that differences in patient populations were not taken into account when
comparing indicators.
8. Critical Incident management –
Risk Management is handled similarly at most facilities, with reporting, tracking
and routine investigations occurring locally, and the more critical incidents being
investigated by the central office.
RECOMMENDATION 8.1: Provide central office medical resources for
expedited thorough investigations of critical incidents and analysis of
trends and patterns with subsequent design and implementation of risk
reduction strategies based on the results.
Although most individual investigations are handled appropriately, what is lacking
is coordination with quality improvement and a big picture approach to identifying
commonalties and implementing change that could prevent further incidents.
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The number of incidents reported indicate that there is a good reporting
mechanism and that employees are not reluctant or fearful to report events.
However, the large number also makes it more difficult to thoroughly investigate
each one to determine root causes or commonalties with other incidents.
Sentinel events need immediate medical review from the state level, which again
speaks to the need of more physicians at the central office to respond to these
investigations. (see recommendation 1.21)
9. Performance Improvement and CQI processes –
Quality processes should identify improvement opportunities and set benchmarks
that are developed by direct healthcare providers through consultation with
consumers and consumer family members. This is in contrast to conducting
studies and collecting data in response to external sanctions, regulatory
agencies, or imposed standards. High risk, problem-prone and high volume
procedures should be monitored and tracked, but more importantly, analyzed
and acted upon.
RECOMMENDATION 9.1: Development of quality initiatives should be
focused, positive and proactive, in collaboration with consumers and
providers, and use benchmarks established by national standards. Action
plans should be implemented by providers, and supported and monitored
by management.
Quality improvement processes should be closely tied into operations, and
therefore requires the participation and support of management. Supervisors
and administrators should not only be aware of quality reports and findings, but
also actively involved in effecting change related to discovered improvement
opportunities. Committee composition and defined committee reporting and
information flow through the organizational chart can facilitate upper
management involvement.
RECOMMENDATION 9.2: Quality initiatives must contain components of
education, networking, and technology, and be organized and orchestrated
through the Division, to create a culture of quality.
More important than the implementation and performance of quality studies and
processes, even if coordinated system-wide, is creating a culture of quality. This
concept must originate at the central office and disseminate throughout the
organization. This is a difficult and gradual task. Mandates to reach goals or
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objectives without providing the tools, support, and resources will not achieve this
goal and it will require a comprehensive approach, including inclusive education
and instructional activities. It will require seeking out best practices, utilizing
networking and information transfer technologies, as well as the promotion and
celebration of successes as they occur within and between each facility. This is
another area of opportunity for collaboration with advocates and advisors.
Promoting and recognizing these successes fuels a culture of quality. A
sustained commitment to instilling a culture of quality in a system that is
transformed in its workforce and operations will galvanize community, family, and
advocacy support. Successes can also attract media attention, adding further to
the momentum of improvement. At the present time, this report focuses more so
on fundamental aspects of care and operations. However, as the system
evolves and improves, creating a culture of quality should soon rise to the
forefront in systems planning and prioritization.
RECOMMENDATION 9.3: Data collection, for whatever purpose, should
always be segregated by patient population: mental health (i.e.
adult/adolescent), forensic and developmentally disabled.
Methods of reporting also impact the effectiveness of quality improvement
activities. For example, some processes looking at key indicators such as
patient injury rates, elopements, hours of restraint and seclusion, readmission
rates, length of stay are compared from facility to facility. However, quality data
that compares hospital performances as a whole is invalid because of the vast
differences in patient composition of each facility. Although all treated in the
same facility, within the same system, and under the same Division within DHR,
adult mental health, adolescent mental health, forensic, and developmentally
disabled patient populations are different in their needs, outcomes, and risk
factors. In addition, each regional hospital functions within its own unique local
mental health system. Comparing client injury rates between a facility that has a
high DD population to one that has little to none dilutes the usefulness of the
data. Tracking separately the number of elopements from unlocked DD buildings
versus elopements from locked secure units is more meaningful than evaluating
total number of elopements between facilities.
10. Patient and Family –
RECOMMENDATION 10.1: The system as a whole needs to embrace the
recovery model, including the employment of both patient advocates and
peer specialists for staff education and enhancement of treatment
programs.
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Clinicians and staff members must exemplify attitudes that consumers have the
ability to participate in their treatment decisions. This need is further reinforced by
the fact that most admissions to state facilities are involuntary. Therefore
providers can actually diminish the capacity of consumers to take control and
manage their own illnesses by not adjusting their mindset. The patients’ decision
making ability must be expected, solicited, and supported. Although the State of
Georgia is a leader in the development of the Peer Specialist Program, this
position was not seen to be consistently employed and utilized throughout the
hospitals. Because of the Division’s commitment and work in peer support, there
is a real opportunity here to integrate and galvanize recover-based approaches
and shared decision making.
RECOMMENDATION 10.2: Incorporating informed patient-centered
treatment and decision making as a standard of care across the system will
require system policy, sufficient numbers of trained and competent staff
members and a standardized practice of communication.
Treatment teams were not always conducted across the system with the patient
present. Therefore, the patient’s ability to participate in the design and
implementation of their inpatient treatment was not always offered. Family
involvement and support in treatment and the outpatient recovery plan is limited
by the lack of family communication. Families are a tremendous asset and
support in treatment planning. Families are so well attuned to the physical health
of their loved ones that they can be of great assistance to the clinical staff in the
assessment and care of medical conditions and pain. Similarly, their knowledge
of their loved one’s mental health is a tremendous source of information and
guidance in treatment planning. Georgia’s mental health system should make
full use of this rich and willing asset. This partnership will greatly enhance patient
assessment treatment planning and customer satisfaction. Staffing levels and
responsibilities need to be addressed (as outlined earlier) in support of greater
access to and involvement with family members in the care of persons who are
hospitalized. Family involvement should occur at all stages of hospitalization
(assessment, stabilization, aftercare planning) and should be welcomed in
treatment planning.
RECOMMENDATION 10.3: Participation with consumers, families and
advocates should be encouraged through participation with current groups
and organizations, and also through formation of Advisory Boards whose
specific purpose is evaluating and providing feedback on services.
Consumers, families and advocates have not had sufficient opportunity to
provide feedback on and input into the design of treatment systems and the
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delivery of care. The benefit of encouraging participation, soliciting comment,
and incorporating the responses is not only an improved system of care, but
relationship building with groups where strong affiliations are advantageous.
This is another area of great opportunity.
RECOMMENDATION 10.4: Continue full implementation of the MANDT
system with ongoing analysis of need for alternative/additional resources
for safe and effective patient/milieu management in the absence of
seclusion/restraint interventions.
The practical elimination of use of seclusion and restraint is commendable,
however, this seems to have been done more by mandate than by elimination of
need or corresponding development of other effective interventions. Where fully
implemented, the MANDT system is evidenced to be very effective; however
some facilities have lagged behind on the training schedule. The incidence of
patient and staff assaults, some with serious injury or consequences, imply that
the elimination of this procedure was not without some consequence since
effective measures of patient and milieu management were not simultaneously
employed.
11. Patient Treatment and Management –
RECOMMENDATION 11.1: Physical modifications, renovations or other
measures such as structured programming, improved staffing mix and
levels, and creative patient management must be taken to address safety
issues created by limited space.
Units visited at many of the facilities were limited in space, and sometimes the
patient area was isolated from the nurse’s station with 1-3 Health Service
Technicians supervising patient group activities. Confining patients who may be
agitated, delusional, detoxifying and/or aggressive to small, congested areas can
provoke patient to patient and/or patient to staff altercations. In an ideal
environment, patients should have common areas that are not crowded, and
allow for personal space without isolation. Professional staff should be
accessible and available for constant observation and quick intervention.
RECOMMENDATION 11.2: Continue efforts to insure that active
programming is being scheduled and provided both on the units and in the
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Treatment Mall with an appropriate balance between therapeutic and
recreational activities.
Programming on inpatient units not only plays a role in active treatment, but is
also an effective patient management tool. Patients engaged in activities are
more easily supervised, less likely to be bored, and less likely to get into patient
altercations. A central office report is submitted weekly from each facility that
reports the number of hours of treatment scheduled and provided. This report
reflects hours counted that can include diversionary activities, individual or oneto-one encounters, and treatment mall activities which occur simultaneously, thus
providing information that is difficult to clarify on the quality and quantity of
programming any individual patient may have access to or be involved in.
Programming should include a combination of therapeutic activities and
recreational activities, and should be provided not only in Treatment Malls, but
also on patient care units when patients are not allowed to leave for off-unit
programming.
The Treatment Malls observed at most facilities allow for patients to attend offunit programming. The Mall also gives patients a choice of activities they can
participate in. The advantages of the Mall are that patients are allowed to leave
the crowded units for what is usually a more spacious area, have an opportunity
to participate in a variety of activities, and can be active in their treatment
choices. The disadvantages are that not all patients are allowed to leave, and
the ones left on the unit were not observed to be offered many structured
activities. Ironically, these patients are those that may be most in need of
therapy. The Mall also allows patients to “opt out” of treatment for diversional or
recreational activities. Both of these disadvantages could be addressed with
stronger programming both in the Mall and on the unit. This is an area of great
opportunity to enhance care with improved staffing levels and responsibilities,
greater involvement of peer support specialists, and a revitalization of
programming. Active treatment planning wherein patients and families are
engaged and partnering in care will greatly enhance patient care and customer
satisfaction.
RECOMMENDATION 11.3: Continue to pursue best practices in the use of
medications and the monitoring for effects
In this audit, we observed generally appropriate use of psychotropic medications,
both in terms of the indications for use of these medications as well as the
appropriate dosages. These are important considerations, particularly given the
patients served in Georgia’s public mental health system. The appropriate use
and access to a wide range of medicines in these facilities is commendable. We
also observed where medication response and side effects were not evaluated
over time. This is an important area for improvement. Additionally, we observed
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many instances of polypharmacy. This is a complex treatment issue, with
national rates of over 1/3 of patients receiving 2 antipsychotics at the same time.
Polypharmacy is a poorly understood yet common practice. Against this
background, it is important that clinicians in Georgia’s facilities carefully evaluate
over time the risk and benefit of polypharmacy. Additionally, the Division should
continue to ensure best practices in the use of psychotropic medications.
LIMITATIONS OF THIS AUDIT AND REPORT
It is important to recognize that although this audit identifies many opportunities
for change, it is limited in its scope. The audit focused on the state hospitals and
did not address the care within the full delivery system. Community systems,
outpatient programs, emergency and long term care options all play a role in the
utilization and measurement of success of inpatient treatment. Inpatient systems
are also dependent on the performance of and cooperation with the criminal
justice system, and breakdowns within that system will also be exposed when
looking at inpatient mental health care. Thus, the audit’s focus on hospitals does
not give a comprehensive review of the continuity of care.
Even with an excellent team of professionals, a detailed audit tool and full
cooperation with each hospital, surveys were conducted over a time period of 2-3
days, and many details may have been missed. Certain aspects of care were
not a focus. This survey was also not comprehensive in examining central office
or even regional oversight, performance or interventions in the delivery of patient
care, which are also critical factors in ultimate hospital performance. Our team
did pay attention to environment of care issues during the audit. However, we
did not assess capital planning and resources for buildings at each hospital. This
is obviously and important aspect in considering treatment and service planning.
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CONCLUDING REMARKS
Georgia’s public mental health system provides care to patients who have
complex needs, including (now more appreciated) substantial medical and
substance abuse co-occurring illnesses. In conducting this audit we observed in
each hospital, evidence of compassionate and quality care, given by committed
staff. We also observed areas where care can be improved upon. In considering
the improvements and recommendations outlined in this report, the commitment
of the Division’s leadership and the support of the hospital staff are major
resources to catalyze the momentum for future improvements. In this document,
building upon the finding(s) and recommendations in 7 other documents which
provide a comprehensive individual evaluation of each facility, we have provided
specific recommendations for system-wide improvement.
Although it is evident in the review of each hospital that they are a part of a
bigger system, in many ways each facility operates independently. Benefits
could definitely be derived from a coordinated and consistent statewide system.
Many issues need to be addressed at the state level, as individual facilities are
naturally unable to affect the changes needed. At the same time, the variances
between facilities must be recognized, with acknowledgement of strengths,
weaknesses and unique characteristics of each hospital. In some cases,
statewide conformity, system compliance could dilute some of the inherent
advantage to individual hospital performance. This dynamic tension is common
to public mental health systems across the country. It is also important to
appreciate that patients receive their care within the local system of care.
Therefore, how well and in what manner each hospital integrates within its own
system of care is a consideration key toward achieving a seamless continuity of
care. These local relationships should continue to be fostered and developed.
Finally, performance improvement is an ongoing process, and this report
provides only a launching pad for change. Building upon the recommendations
contained within this report, it is imperative that a performance improvement
program is established that is comprehensive and continuous, developing a
culture of quality within the system. Effective performance measures must be
established to monitor, measure and evaluate system improvements that are
implemented.
The complexity and extent of findings speak to longstanding difficulties whose
origins precede way beyond the current staff or leadership. In addition, the
process of effecting change, implementing improvements and correcting
deficiencies to turn the system around will be slow and deliberate, requiring
continued commitment and support over time. All stakeholders will need to
contribute to this deliberate process which will require time, resources, and
ongoing support for the Division leadership.
119
The support, cooperation, and participation of the individual hospitals staff and
leadership, the central office staff and leadership, NAMI, MHA and other
consumer networks is acknowledged and appreciated in the performance of this
audit.
120
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