Environment of Care
The FRM and IT staff member worked together to view video on the facility server. The RRM requested the video be saved, the FRM was interrupted and never returned to the task to include the video vault. The video was never saved.
Video viewed but did not save EC 10
Although a patient has no involved family, he does have a support person. The Inpatient therapist fails to involve the support person in discharge planning. The patient is placed at a friend's house instead of the support person's home. The patient is unhappy with the plan
Failure to involve support person DP 1
A patient receives divorce papers while in treatment at the facility on the 7a-7p shift. The day shift fails to provide communication to the 7p-7a shift regarding the patient's response to divorce papers, and acting out behavior on the unit.
Communication re Circumstantial Life Changes C5
Contraband is exchanged between an Inpatient and PHP patient while in the cafeteria. The inpatient was at lunch during a wrong lunch period during the weekend
Conraband issues PHOP5
Physician's order is so illegible, medication dosage cannot be determined
Illegible Documentation D3
A gurney in the common area used when a transfer patient is brought to the unit is left unescorted. A delusional geriatric patient tries to lay down on the gurney, rolls off and cutting her arm.
Equipment Used for Unintended Purpose EC 9
Medications were brought in by patient at admission. Patient was detoxed off his home medications. Patient's admission medications were returned to patient without a physician order.
Meds returned to patient w/o physician order DP 8
Treatment team communication is not provided to therapist, he is unaware of a change in the discharge plan for the patient. The patient is to return to family instead of a group home. The patient is discharge to a group home.
Communication re treatment team C6
Absent/failed Suicide Risk Assessment PHOP4
Vital signs are entered into HCS; however, are not printed for the record due to a unit printer issue. The patient is transferring to a medical facility for change in condition. No copy of the vitals is provided with the patient upon transfer.
Electronic documentation issues D4
The 7p-7a mental health tech positions his chair near the nursing station; however, he is unable to view both patient hallways and a blind spot within one hallway. As a result, patients move from one patient room to another.
Unable to Visualize/View Area/Blind Spot EC 7
Documentation is is not in record that family received education on suicide risk factors.
Failure re discharge education DP 4
Two patients are assigned together to share a room. One patient has a SAO victim history one has a SAO Aggressor history. The nursing unit fail to consider the patients SAO history in room placement.
What is Absent/failed roommate assignment MHR3?
A patient in Outpatient has missed two program days and follow-up calls are not conducted.
Absent/fail Missed Appointment Process PHOP1
X-ray results for a patient with a possible fracture to her wrist are never received while patient is in treatment. Results return post patient discharge.
Failure re diagnostics (x-rays,labs) DT1
An older door between 2 units is difficult to lock. The lock will not engage properly resulting in the ability of the door to be pushed open. An SAO event occurs as a result of the door being pushed open 11p-7a.
Absent/failed involving environment EC 6
The Crisis Safety Plan was not discussed with the patient's support person; therefore, support person is unaware of patient's triggers.
Failure re documenting support person in the Crisis Safety Plan. DP 2
Critical lab findings are provided to day shift RN who does not provide communication to next shift or Physician.
Communication re critical lab/imaging C8
No emergency contact number is provided by the PHP patient. The blank field was overlooked at the time.
Emergency contact issue PSOP3
Patient complained of gastro issues upon admission and for two subsequent days. No communication provided to the physician for a physician consult. On the third day, patient ran a temperature and had to be transferred to a hospital for an emergency appendectomy.
Delay in Medical consult DT4
A medical response code is called on a unit with poor response from other units. The code is investigated by the FRM and results in identification that the announcement speaker is not working on all units.
Inability to Hear Alarms/Announcement EC 8
Patient has 2 previous suicide attempts. Pt was provided with a 30-day supply despite treatment team recommendations that patient would receive only a two-week supply of medications with an immediate appointment for aftercare.
DC scripts over 15-day supply w/o MD order DP9
PHP patient arrives at Intake as a step-up but recent communication regarding SI is not provided to Intake assessor, by PHP staff. Patient is discharged home with education for follow-up with OP.
Communication re Intake process C1
Absent/failed Family/Support involvement PHOP6
During treatment a patient was in a physical confrontation with another patient and suffered an injury to his orbital region of his right eye. The incident occurred in the early evening and the physician was notified. The physician never responded to the call. The patient was later transferred per an order from the Medical Director.
Physician did not provide care timely DT 3