HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure patient observations were conducted by staff every 15 minutes as ordered by the physician for 3 (#R8, #R9, #10) of 3 patients observed on a hospital-provided video recording (see findings tag A-0144); and

2) Failing to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment was completed for 3 (#3, #11, #14) of 7 (#1 - #5, #11, #14) patient records reviewed for accurate observation levels from a total of 14 sampled patients and 10 random patients (see findings tag A-0144).

Based on record review and interview, the hospital failed to ensure each patient who filed a grievance was provided a written notice of the hospital's decision regarding the resolution of the grievance for 1 (R1) of 2 (R1, R8) grievances reviewed.
Findings:

Review of the hospital's complaints and grievances revealed the following grievance, filed by Patient R1 on 02/15/17, alleging sexual abuse by hospital staff members:

Summary of complaint/grievance: Pt. reports 1) He was offered sexual favors by a male tech during his stay and was offered to watch pornography on tech's phone 2) Pt. was approached by female employee who gave her phone number. Pt. reports that on discharge he contacted staff person, went to her house, took pills, and drank alcohol.

Status/Outcome: Pt. provided number to staff person and we were able to determine it was a patient not a staff member. A review of the video shows no evidence of improper actions with pt. (patient) and male staff members. All staff were reminded not to put themselves in compromising situations that could look unprofessional when viewed by cameras.

In an interview on 03/21/17 at 4:15 p.m. with S1ADM, he indicated he had investigated the above-referenced complaint and found it to be unsubstantiated. He confirmed he had not sent written notice of the hospital's decision regarding resolution of the grievance to Patient R1 after the investigation was completed.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to ensure patient observations by staff were conducted every 15 minutes as ordered by the physician for 3 (R8, R9, #10) of 3 patients observed on a hospital-provided video recording; and

2) Failing to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment is completed for 3 (#3, #11, #14) of 7 (#1 - #5, #11, #14) patient records reviewed for accurate observation levels from a total of 14 sampled patients and 10 random patients.
Findings:

1) Failing to ensure patients were observed as ordered by the physician:
Observation on 03/20/17 at 4:00 p.m. with S1ADM of video surveillance of Hall A on the night of 03/19/17 and the morning of 03/20/17 revealed neither S23MHT nor any other staff member conducted the physician-ordered every 15 minute observations on Patient R8, Patient R9 or Patient #10 from 5:00 a.m. until 7:00 a.m. (2 hours).

Review of a hospital provided list of patients and diagnosis revealed the following:
Patient R8 had been admitted on 03/17/17 with diagnoses including Bipolar Disorder Unspecified and Alcohol Abuse. Patient R9 had been admitted on 03/12/17 with a diagnosis of Recurrent Major Depressive Disorder. Patient #10 had been admitted on 03/07/17 with a diagnosis of Altered Mental Status.

Review of the 15 minute observation sheets revealed S23MHT had initialed on 03/20/17 from 5:00 a.m. through 6:45 a.m. that he had observed Patients R8, R9 and Patient #10 every 15 minutes.

In an interview on 03/20/17 at 4:30 p.m. with S1ADM, he verified S23MHT did not observe Patients R9, R8 or #10 every 15 minutes as ordered by the physician. He also verified S23MHT had documented on the patients' observation sheets that he had observed the patients every 15 minutes although he had not.

In an interview on 03/20/17 at 6:05 p.m., S23MHT indicated he worked the night shift on 03/19/17 (7:00 p.m. to 7:00 a.m. on 03/20/17). When informed that observation of the hospital-provided video by the surveyor with S1ADM present revealed no observation of any staff member in the hall on 03/20/17 between 5:00 a.m. and 7:00 a.m., S23MHT indicated he missed some every 15 minute observations while he was doing some of the assigned MHT duties such as getting all patients up and having them go to the day room at 6:00 a.m., making sure the shower is clean, taking the dirty linen to the laundry (located in the adjacent nursing home), collecting all trash, taking the coolers to be sterilized to the dietary department in the adjacent nursing home, making the tea and lemonade, and taking the dietary sheets to the dietary department in the adjacent nursing home. S23MHT confirmed he documented that he made the observations, but he did not actually make the observations. When asked if he was aware that this was fraudulent documentation, he answered "yes."

2) Failing to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment is completed:
Review of the "Suicide And Homicide Risk Assessment" form, presented as the form currently being used to conduct suicide and homicide risk assessments by the nurse and social workers by S1ADM, revealed that each risk factor is assessed and rated from "no risk" to "high risk." If the patient scores 3 or more in the high risk category for suicide or homicide, the patient is considered high risk, regardless of the score. Any patient admitted due to a suicide or homicide attempt will be considered high risk and placed on the high risk precautions. Further review revealed the high risk precaution required 1:1 constant supervision at arm's length.

Review of the hospital policy titled "Suicidal Risk/Protective Factors Assessment And Precautions", presented as a current policy by S1ADM, revealed that all patients will be LOS upon hospital arrival until a full risk assessment is completed by the admission nurse, and each patient will be assigned a staff member who will begin patient observation documentation immediately. If a patient is actively suicidal or was admitted due to a recent suicide attempt, or is non-compliant with the assessment, immediately place the patient on LOS, and the patient will remain on LOS until the psychiatrist examines the patient.

Review of the hospital policy titled "Homicidal Risk Assessment And Precautions", presented as a current policy by S1ADM, revealed that all patients will be LOS upon hospital arrival until a full risk assessment is completed by the admission nurse, and each patient will be assigned a staff member who will begin patient observation documentation immediately. If a patient is actively homicidal or was admitted due to a recent homicide attempt, immediately place the patient on LOS until the psychiatrist examines the patient.

Review of the hospital policy titled "Patient Observation", presented as a current policy by S1ADM, revealed that 1:1 observation was defined as "at arm's length." Constant observation was defined as "within staff visual field at all times (LOS)."

Patient #3
Review of Patient #3's medical record revealed she was admitted on 03/13/17 at 11:00 p.m. with a diagnosis of Major Depressive Disorder and Urinary Tract Infection. Review of PEC signed on 03/13/17 at 2:55 p.m. revealed a history of Alzheimer's, aggressive towards nursing home staff, violent, and a danger to self and others.

Review of Patient #3's "Suicide And Homicide Risk Assessment", signed by S7RN on 03/13/17 at 11:00 p.m. revealed a note that reads "unable to complete, client (with) Alzheimer's. Client confused & (and) poor historian."

Review of Patient #3's "Psychiatric Evaluation" documented by S4Psych revealed the evaluation was conducted on 03/14/17 at 12:18 p.m.

Review of the MHT observation records presented for Patient #3 revealed no documented evidence of the type of observation that was provided as evidenced by having the box for close observation not checked on the form. The observations documented at 7:00 a.m. revealed she was placed on LOS observation.

No documented evidence was presented by the hospital that revealed that Patient #3 was placed on LOS upon her arrival to the hospital (03/13/17 at 11:00 p.m.) until 7:00 a.m. on 03/14/17, since her suicide and homicide risk assessments were not completed.

In an interview on 03/20/17 at 12:35 p.m., S3LCSW confirmed there was no documented evidence that Patient #3 was placed on LOS upon her arrival to the hospital. She confirmed the suicide and risk assessment were not completed upon Patient #3's arrival to the hospital, and S4Psych didn't evaluate her until 03/14/17 at 12:18 p.m. She further indicated if the RN was unable to perform the risk assessment, Patient #3 was supposed to be placed on the highest precautions which was 1:1 until she was seen by the psychiatrist.

Patient #11
Review of Patient #11's medical record revealed an admission date of 03/11/17 at 1:30 p.m. with an admission diagnosis of Bipolar Disorder, manic with severe Psychosis. Further review revealed an OPC (Order for Protective Custody) dated 03/10/17 at 1:30 p.m. describing the patient's behavior as dangerous to self, dangerous to others, gravely disabled, unwilling to seek voluntary admission, and with a history of synthetic marijuana use. A PEC, dated 03/12/17 at 10:54 a.m., revealed the patient had been OPC'd due to threatening to kill herself with a knife. Further review of the PEC revealed the patient was assessed to be currently suicidal (at the time of the PEC) and was documented as dangerous to self, gravely disabled and unwilling to seek voluntary admission.

Review of Patient #11's Initial Suicide and Homicide Risk Assessment, completed on 03/11/17 at 2:15 p.m., revealed Patient #11 had scored 6 points (High Risk is 3 or more points) on Section I for risk of harm to self (suicide risk) and had scored 9 points (High risk is 3 or more points) on Section II for plan to harm others (homicide risk) on the Assessment tool.

Review of Patient #11's observation sheets and physician's orders revealed the patient was placed on Close Observation, every 15 minute checks, at the time of admission. Further review revealed Patient #11's Psychiatric Evaluation was not completed until 03/12/17 at 10:30 a.m. Patient #11 was not placed on 1:1 Constant Supervision prior to evaluation by a psychiatrist.

In an interview on 03/21/17 at 3:46 p.m. with S19COO, she verified patients scoring high risk should have been placed on 1:1 Observation until an evaluation was conducted by a psychiatrist.

Patient #14
Review of Patient #14's medical record revealed she had been admitted on 03/13/17 at 6:51 p.m. after attempting suicide with pills. Patient #14 also scored 3 in the high risk homicide assessment completed at 7:45 p.m.

Further review revealed she was not placed on high risk precautions (1:1 observation) as per policy until she was evaluated by the psychiatrist on 03/15/17 at 2:32 p.m.

In an interview on 03/21/17 at 3:30 p.m. with S14RN, she said if a patient came in suicidal, the observation level was based on the score on the nurse's risk assessment. S14RN was unaware that if a patient had been actively suicidal they were automatically considered high risk and placed on 1:1 observation.

In an interview on 03/21/17 at 3:45 p.m. with S19COO, she verified Patient #14 should have been placed on 1:1 observation until an evaluation was conducted by a psychiatrist.


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Based on record review and interview, the hospital failed to report alleged allegations of abuse to the Department of Health and Hospitals within 24 hours of receipt of the allegation for 1 (R1) of 2 (R1, R8) sampled patients reviewed for grievances.
Findings:

Review of the hospital policy titled, Patient Rights: Free from Abuse/Neglect/Exploitation, Policy number RI 15, revealed in part: Policy: Patients have the right to be free from mental, physical, sexual and verbal abuse.
Procedure: All cases of suspected abuse/neglect must be reported to a authorities. A person, (including an employee, volunteer or other person) associated with the hospital, who reasonably believes or who knows of information that would reasonably cause a person that the physical or mental health or welfare of a patient of the hospital, who is receiving medical services, has been or will be adversely affected by abuse or neglect by any person shall notify his/her immediate supervisor immediately so that Louisiana Department of Health can be notified in writing within 24 hours.

Review of the hospital's complaints and grievances revealed the following grievance filed by Patient R1 on 02/15/17 alleging sexual abuse by a hospital staff member:

Summary of complaint/grievance: Pt. reports 1) He was offered sexual favors by a male tech during his stay and was offered to watch pornography on tech's phone 2) Pt. was approached by female employee who gave her phone number. Pt. reports that on discharge he contacted staff person, went to her house, took pills, and drank alcohol.

Status/Outcome: Pt. provided number to staff person and we were able to determine it was a patient not a staff member. A review of the video shows no evidence of improper actions with pt. and male staff members. All staff were reminded not to put themselves in compromising situations that could look unprofessional when viewed by cameras.

In an interview on 03/21/17 at 4:15 p.m. with S1ADM, he indicated he had not reported the above-referenced allegations to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of discovery, because he had investigated the complaint and had found it to be unsubstantiated.

Based on record review and interview, the hospital failed to ensure the use of restraints or seclusion was in accordance with a written modification to the patient's plan of care for 3 (#1, #4, #6) of 3 sampled patients reviewed for the use of restraints from a total sample of 14 patients.
Findings:

Review of the hospital policy titled Restraint or Seclusion Use Violent and Non-Violent Behaviors, Policy PC 77-Provision of Care, revealed in part:
Restraint orders are to be written in accordance with modifications to the patient's plan of care.

Patient #1
Review of the medical record for Patient #1 revealed he had been placed into seclusion on 03/19/17 at 1:55 p.m. for violent behaviors. Further review revealed there was no modification to Patient #1's plan of care to include the use of seclusion.

Patient #4
Review of Patient #4's medical record revealed he had been placed in four point restraints on 11/09/16 at 11:20 a.m. for violent behavior. Further review revealed there was no modification to Patient #4's plan of care to include the use of restraints.

Patient #6
Review of the medical record for Patient #6 revealed he had been placed in four point restraints for violent behavior on 01/05/17 from 1:49 p.m. until 4:53 p.m. Further review revealed there was no modification to Patient #6's plan of care to include the use of restraints.

In an interview on 03/21/17 at 1:36 p.m. with S19COO, she verified the patients' care plan should have been updated when patients were placed in restraints or seclusion.

Based on record review and interview, the hospital failed to ensure each order for restraint for the management of violent or self-destructive behavior was renewed every 4 hours for an adult older than 18 years of age for 1 (#4) of 3 (#1, #4, #6) patient records reviewed for restraint use from a total sample of 14 patients.
Findings:

Review of the hospital policy titled Restraint or Seclusion use Violent and Non-Violent Behaviors, Policy PC 77-Provision of Care, revealed in part:
At the end of the above time frames, if the continued use of restraint or seclusion to manage violent or self-destructive behavior is necessary, based on patient assessment, another order is required.

Review of Patient #4's medical record revealed he had been placed in restraints on 11/09/16 at 11:20 a.m. for violent behavior and released at 3:55 p.m. (4 hours and 35 minutes). The original physician's order for Patient #4's restraints for up to 4 hours had not been reordered after the 4 hours had expired.

In an interview on 03/21/17 at 1:36 p.m. with S19COO, she verified a new order should have been obtained if a patient's restraints were going to be continued longer than 4 hours.

Based on record review and interview, the hospital failed to ensure when restraints were used for the management of violent behavior, the patient was seen face-to-face within 1 hour after the initiation of the intervention and evaluated for the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraints for 1 (#6) of 3 (#1, #4, #6) patient records reviewed for restraints from a total sample of 14 patients.
Findings:

Review of the hospital policy titled Restraint and Seclusion: Staff Competency and Training Requirements, Policy PC 66-Provision of Care, revealed in part:
2. Training for individuals authorized to conduct the face-to-face evaluation of a restrained or secluded patient (used to manage violent or self-destructive behavior) include: The patient's immediate situation; The patients reaction to the intervention; The patient's medical and behavioral condition including a review of symptoms, patient history, medications and lab results; and The need to continue or terminate the restraint or seclusion.

Review of the medical record for Patient #6 revealed he had been placed in four point restraints for violent behavior on 01/05/17 from 1:49 p.m. until 4:53 p.m. Further review revealed there was no documented evidence of a 1 hour face-to-face evaluation after the initiation of the restraints.

In an interview on 03/21/17 at 1:36 p.m. with S19COO, she verified a face-to face evaluation should have been done by an RN within an hour of the initiation of restraints.

Based on record review and interview, the hospital failed to ensure the RN who performed the face-to-face evaluation after the initiation of restraints or seclusion consulted with the attending physician as soon as possible after the evaluation for 2 (#1, #4) of 3 (#1, #4, #6) patient records reviewed for restraints or seclusion from a total sample of 14 patients.
Findings:

Review of the hospital policy titled Restraint or Seclusion use Violent and Non-Violent Behaviors, Policy PC 77-Provision of Care, revealed in part:
The attending physician or other LIP (licensed independent practitioner), who is responsible for the patient, must be consulted as soon as possible after completion of the one (1) hour face-to-face exam if this evaluation is conducted by an RN or PA (physician's assistant).

Patient #1
Review of the medical record for Patient #1 revealed he had been placed into seclusion on 03/19/17 at 1:55 p.m. for violent behaviors. Further review revealed a face-to-face evaluation had been completed by S13RN at 2:15 p.m. There was no documented evidence that the physician was notified of the results of the evaluation.

Patient #4
Review of Patient #4's medical record revealed he had been placed in restraints on 11/09/16 at 11:20 a.m. for violent behavior. Further review revealed a face-to-face evaluation had been completed by S22RN at 12:20 p.m. There was no documented evidence that the physician was notified of the results of the evaluation.

In an interview on 03/21/17 at 1:36 p.m. with S19COO, she verified a face-to-face evaluation should have been done within an hour of seclusion or restraint, and the physician notified of the results as soon as possible.

Based on record reviews and interview, the hospital failed to ensure that the data collected for QAPI (quality assessment and performance improvement) was used to identify opportunities for improvement and changes that will lead to improvement as evidenced by failure to have documented evidence of data collected and analyzed for February 2017 and failure to have identified opportunities for improvement that were identified by the survey team from 03/20/17 to 03/22/17.
Findings:

Review of the hospital policy titled "Performance Improvement Plan", presented as the current plan by S2IDON, revealed that the plan allows for a systematic, coordinated, continuous data-driven approach to improving performance focusing upon the processes and mechanisms that address these values. The program has the responsibility for monitoring every aspect of care and service, including contracted services, from the time the patient enters the hospital through diagnosis, treatment, recovery, and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety. Further review revealed objective and statistically valid performance measures are identified for monitoring and assessing processes and outcomes of care including those affecting a large percentage of patients, and/or place patients at serious risk if not performed well, or performed when not indicated, or not performed when indicated, and/or have been or likely to be problem-prone. Data is collected to assess care when benchmarks or thresholds are reached in order to identify opportunities to improve performance or resolve problem areas. Action is taken is to correct identified problem areas or improve performance and evaluated to determine the effectiveness of the actions taken with documentation of the improvement in care.

Review of the "New Orleans Hospital Annual PI (performance improvement) Reporting Tool 2016" and "Committee of the Whole Meeting Minutes Jan (January) 2017", presented by S2IDON, revealed problems identified in the 2016 annual QAPI review remained in the data submitted for January 2017. Further review revealed the action to be taken in January 2017 was to continue to monitor and educate staff.

No QAPI data was presented that had been collected for February 2017 as of the time of the survey exit on 03/22/17 at 3:40 p.m.

Review of the problems identified in the QAPI data revealed no documented evidence that problems had been identified related to documentation of groups attended or the reason why the group was not attended by the patient and related to discharge planning.

In an interview on 03/22/17 at 1:00 p.m., S2IDON indicated the February 2017 data had been collected by S12LPN but not yet analyzed. She further indicated she did not have the data available to present to the surveyor. S2IDON indicated they have had an approximate 70% turnover in staff, so education is what's needed. She confirmed that the problems identified by the survey team related to documentation of group attendance or the reason why not attended and related to discharge planning had not been identified by the QAPI committee. She confirmed that the problems identified by the survey team during the survey conducted on 03/20/17 through 03/22/17 had either not been identified by the hospital's QAPI program or had not had an effective corrective action plan implemented to address the problem.

Based on record reviews, interviews and observations, the hospital failed to meet the requirements of the Condition of Participation for Nursing services as evidenced by:

1) Failing to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:
a) The RN failed to ensure observations were made by the MHT as ordered by the psychiatrist on the night shift of 03/19/17.
b) The RN failed to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment was completed for 3 (#3, #11, #14) of 3 patient records reviewed for accurate observation levels from a total of 14 sampled patients and 10 random patients.
c) The RN failed to assess patients and document the assessment after a fall (#3, R4, R5) and after an altercation (R2, R3) for 5 (#3, R2, R3, R4, R5) of 5 patient records reviewed for an RN assessment of a patient after a fall or altercation from a total of 14 sampled patients and 10 random patients.
d) The RN failed to assess and document the assessment of patients experiencing a change in condition such as abnormal vital signs (#3) or abnormal capillary blood glucose results (#8) for 2 (#3, #8) of 7 (#1 - #5, #8, R5) patient records reviewed for RN assessment from a total of 14 sampled patients and 10 random patients.
e) The RN failed to ensure Accuchecks (capillary blood glucose checks) were assessed as ordered by the physician for 1 (#3) of 4 (#3, #7, #8, #9) diabetic patient records reviewed for Accuchecks from a total of 14 sampled patients and 10 random patients (see findings in tag A0395).

2) Failing to ensure there was a plan for administrative authority for nursing services to ensure the nursing services was under the direction of one RN employed by the hospital in the absence of the DON as evidenced by having coverage for nursing services provided by DONs from other sister hospitals on the weekend of 03/18/17 and 03/19/17 and on 03/21/17 (see findings in tag A0386).

Based on interviews, the hospital failed to ensure there was a plan for administrative authority for nursing services to ensure the nursing services was under the direction of one RN employed by the hospital in the absence of the DON as evidenced by having coverage for nursing services provided by DONs from other sister hospitals on the weekend of 03/18/17 and 03/19/17 and on 03/21/17.
Findings:

In an interview on 03/21/17 at 8:10 a.m., S1ADM indicated S2IDON was not available on the weekend that included 03/18/17 and 03/19/17. He further indicated the DON from Hospital A was available to him for any medical issues that may arise.

In an interview on 03/21/17 at 11:00 a.m., S1ADM indicated S2IDON was off this day.

In an interview on 03/22/17 at 7:43 a.m., S2IDON indicated the hospital usually uses a DON from one of their sister hospitals to replace the DON at the New Orleans location when the DON is off. She confirmed that no RN employed at the hospital had been designated as the registered nurse in charge of nursing services at times when she (S2IDON) was unavailable and/or on leave from the hospital.

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:
1) The RN failed to ensure observations were made by the MHT as ordered by the psychiatrist on the night shift of 03/19/17.
2) The RN failed to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment was completed for 3 (#3, #11, #14) of 3 patient records reviewed for accurate observation levels from a total of 14 sampled patients and 10 random patients.
3) The RN failed to assess patients and document the assessment after a fall (#3, R4, R5) and after an altercation (R2, R3) for 5 (#3, R2, R3, R4, R5) of 5 patient records reviewed for an RN assessment of a patient after a fall or altercation from a total of 14 sampled patients and 10 random patients.
4) The RN failed to assess and document the assessment of patients experiencing a change in condition such as abnormal vital signs (#3) or abnormal capillary blood glucose results (#8) for 2 (#3, #8) of 7 (#1 - #5, #8, R5) patient records reviewed for RN assessment from a total of 14 sampled patients and 10 random patients.
5) The RN failed to ensure Accuchecks (capillary blood glucose checks) were assessed as ordered by the physician for 1 (#3) of 4 (#3, #7, #8, #9) diabetic patient records reviewed for Accuchecks from a total of 14 sampled patients and 10 random patients.
Findings:

1) The RN failed to ensure observations were made by the MHT as ordered by the psychiatrist on the night shift of 03/19/17:
Observation on 03/20/17 at 4:00 p.m. with S1ADM of video surveillance of Hall A on the night of 03/19/17 and the morning of 03/20/17 revealed neither S23MHT nor any other staff member conducted the physician-ordered every 15 minute observations on Patient R8, Patient R9 or Patient #10 from 5:00 a.m. until 7:00 a.m. (2 hours).

Review of a hospital provided list of patients and diagnosis revealed the following:
Patient R8 had been admitted on 03/17/17 with diagnoses including Bipolar Disorder Unspecified and Alcohol Abuse. Patient R9 had been admitted on 03/12/17 with a diagnosis of Recurrent Major Depressive Disorder. Patient #10 had been admitted on 03/7/17 with a diagnosis of Altered Mental Status.

Review of the 15 minute observation sheets revealed S23MHT had initialed on 03/20/17 from 5:00 a.m. through 6:45 a.m. that he had observed Patients R8, R9 and Patient #10 every 15 minutes.

In an interview on 03/20/17 at 4:30 p.m. with S1ADM, he verified S23MHT did not observe Patients R9, R8 or #10 every 15 minutes as ordered by the physician. He also verified S23MHT had documented on the patients' observation sheets that he had observed the patients every 15 minutes although he had not.

In an interview on 03/20/17 at 6:05 p.m., S23MHT indicated he worked the night shift on 03/19 17 (7:00 p.m. to 7:00 a.m. on 03/20/17). When informed that observation of the hospital-provided video by the surveyor with S1ADM present revealed no observation of any staff member in the hall on 03/20/17 between 5:00 a.m. and 7:00 a.m., S23MHT indicated he missed some every 15 minute observations while he was doing some of the assigned MHT duties such as getting all patients up and having them go to the day room at 6:00 a.m., making sure the shower is clean, taking the dirty linen to the laundry (located in the adjacent nursing home), collecting all trash, taking the coolers to be sterilized to the dietary department in the adjacent nursing home, making the tea and lemonade, and taking the dietary sheets to the dietary department in the adjacent nursing home. S23MHT confirmed he documented that he made the observations, but he did not actually make the observations.

2) The RN failed to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment was completed:
Review of the "Suicide And Homicide Risk Assessment" form, presented as the form currently being used to conduct suicide and homicide risk assessments by the nurse and social workers by S1ADM, revealed that each risk factor is assessed and rated from "no risk" to "high risk." If the patient scores 3 or more in the high risk category for suicide or homicide, the patient is considered high risk, regardless of the score. Any patient admitted due to a suicide or homicide attempt will be considered high risk and placed on the high risk precautions. Further review revealed the high risk precaution required 1:1 constant supervision at arm's length.

Review of the hospital policy titled ""Suicidal Risk/Protective Factors Assessment And Precautions", presented as a current policy by S1ADM, revealed that all patients will be LOS upon hospital arrival until a full risk assessment is completed by the admission nurse, and each patient will be assigned a staff member who will begin patient observation documentation immediately. If a patient is actively suicidal or was admitted due to a recent suicide attempt, or is non-compliant with the assessment, immediately place the patient on LOS, and the patient will remain on LOS until the psychiatrist examines the patient.

Review of the hospital policy titled "Homicidal Risk Assessment And Precautions", presented as a current policy by S1ADM, revealed that all patients will be LOS upon hospital arrival until a full risk assessment is completed by the admission nurse, and each patient will be assigned a staff member who will begin patient observation documentation immediately. If a patient is actively homicidal or was admitted due to a recent homicide attempt, immediately place the patient on LOS until the psychiatrist examines the patient.

Review of the hospital policy titled "Patient Observation", presented as a current policy by S1ADM, revealed that 1:1 observation was defined as "at arm's length." Constant observation was defined as "within staff visual field at all times (LOS)."

Patient #3
Review of Patient #3's medical record revealed she was admitted on 03/13/17 at 11:00 p.m. with a diagnosis of Major Depressive Disorder and Urinary Tract Infection. Review of PEC signed on 03/13/17 at 2:55 p.m. revealed a history of Alzheimer's, aggressive towards nursing home staff, violent, and a danger to self and others.

Review of Patient #3's "Suicide And Homicide Risk Assessment", signed by S7RN on 03/13/17 at 11:00 p.m. revealed a note that reads "unable to complete, client (with) Alzheimer's. Client confused & (and) poor historian."

Review of Patient #3's "Psychiatric Evaluation" documented by S4Psych revealed the evaluation was conducted on 03/14/17 at 12:18 p.m.

Review of the MHT observation records presented for Patient #3 revealed no documented evidence of the type of observation that was provided as evidenced by having the box for close observation not checked on the form. The observations documented at 7:00 a.m. revealed she was placed on LOS observation.

No documented evidence was presented by the hospital that revealed that Patient #3 was placed on LOS upon her arrival to the hospital (03/13/17 at 11:00 p.m.) until 7:00 a.m. on 03/14/17, since her suicide and homicide risk assessments were not completed.

In an interview on 03/20/17 at 12:35 p.m., S3LCSW confirmed there was no documented evidence that Patient #3 was placed on LOS upon her arrival to the hospital. She confirmed the suicide and risk assessment were not completed upon Patient #3's arrival to the hospital, and S4Psych didn't evaluate her until 03/14/17 at 12:18 p.m. She further indicated if the RN was unable to perform the risk assessment, Patient #3 was supposed to be placed on the highest precautions which was 1:1 until she was seen by the psychiatrist.

Patient #11
Review of Patient #11's medical record revealed an admission date of 03/11/17 at 1:30 p.m. with an admission diagnosis of Bipolar Disorder, manic with severe Psychosis. Further review revealed an OPC (Order for Protective Custody) dated 03/10/17 at 1:30 p.m. describing the patient's behavior as dangerous to self, dangerous to others, gravely disabled, unwilling to seek voluntary admission, and with a history of synthetic marijuana use. A PEC, dated 03/12/17 at 10:54 a.m., revealed the patient had been OPC'd due to threatening to kill herself with a knife. Further review of the PEC revealed the patient was assessed to be currently suicidal (at the time of the PEC) and was documented as dangerous to self, gravely disabled and unwilling to seek voluntary admission.

Review of Patient #11's Initial Suicide and Homicide Risk Assessment, completed on 03/11/17 at 2:15 p.m., revealed Patient #11 had scored 6 points (High Risk is 3 or more points) on Section I for risk of harm to self (suicide risk) and had scored 9 points (High risk is 3 or more points) on Section II for plan to harm others (homicide risk) on the Assessment tool.

Review of Patient #11's observation sheets and physician's orders revealed the patient was placed on Close Observation, every 15 minute checks, at the time of admission. Further review revealed Patient #11's Psychiatric Evaluation was not completed until 03/12/17 at 10:30 a.m. Patient #11 was not placed on 1:1 Constant Supervision prior to evaluation by a psychiatrist.

In an interview on 03/21/17 at 3:46 p.m. with S19COO, she verified patients scoring high risk should have been placed on 1:1 Observation until an evaluation was conducted by a psychiatrist.

Patient #14
Review of Patient #14's medical record revealed she had been admitted on 03/13/17 at 6:51 p.m. after attempting suicide with pills. Patient #14 also scored 3 in the high risk homicide assessment completed at 7:45 p.m.

Further review revealed she was not placed on high risk precautions (1:1 observation) as per policy until she was evaluated by the psychiatrist on 03/15/17 at 2:32 p.m.

In an interview on 03/21/17 at 3:30 p.m. with S14RN, she said if a patient came in suicidal, the observation level was based on the score on the nurse's risk assessment. S14RN was unaware that if a patient had been actively suicidal they were automatically considered high risk and placed on 1:1 observation.

In an interview on 03/21/17 at 3:45 p.m. with S19COO, she verified Patient #14 should have been placed on 1:1 observation until an evaluation was conducted by a psychiatrist.

3) The RN failed to assess patients and document the assessment after a fall and after an altercation:
Fall:
A request was made on 03/21/17 at 8:10 a.m. to S1ADM and 03/22/17 at 7:43 a.m. to S2IDON for a policy related to the RN's assessment of a patient after a fall or altercation. As of the time of exit on 03/22/17 at 3:40 p.m., no such policy was presented to the surveyor.

Patient #3
Review of Patient #3's medical record revealed a "Contact Note" documented on 03/17/17 at 7:20 a.m. by S14RN that the activity director had notified the nursing staff that he had to assist Patient #3 after she fell trying to get out her wheelchair. Further documentation revealed "patient denied hitting her head, and also denied pain. S4Psych notified." There was no documented evidence of an RN assessment for injury. Review of Patient #3's "Daily Nursing Flowsheet" for the day shift (7:00 a.m. to 7:00 p.m.), documented by S14RN on 03/17/17 at 6:08 p.m., revealed no documented evidence of the fall and an assessment by an RN for injury.

In an interview on 03/20/17 at 2:06 p.m., S3LCSW confirmed there was no documented evidence in Patient #3's medical record of an assessment by an RN after the fall on 03/17/17.

Patient R4
Review of Patient R4's medical record revealed documentation by S25LPN on 03/07/17 at 11:30 a.m. that she had approached the staff nurse and stated she fell outside in the courtyard during tech activity. Further review review revealed minor abrasions were observed to her right knee and left palm, and S4Psych and the NP were notified. There was no documented evidence of an RN assessment after the fall.

Review of the "Unusual Occurrence/Incident Report" documented by S25LPN on 03/07/17 at 11:30 a.m. revealed vital signs were documented. There was no documented evidence that an RN assessed Patient R4 after the fall.

In an interview on 03/20/17 at 4:03 p.m., S3LCSW confirmed there was no documented evidence in Patient R4's medical record of an assessment by an RN after she fell on 03/07/17.

Patient R5
Review of the "Unusual Occurrence/Incident Report" documented by S14RN on 03/03/17 at 2:16 p.m. revealed that on 03/03/17 at 1:45 p.m. the MHT reported to the nursing staff that she found Patient R5 lying on the floor in her room. Further review revealed the patient was "disorganized & (and) disoriented. Pt (patient) stated "I was day dreaming and I fell." Pt denied hitting her head and also denied pain. Vital signs assessed and stable."

Review of Patient R5's "Contact Note" documented by S14RN on 03/03/17 at 3:03 p.m. revealed the above information with the addition of "no apparent distress or injury noted. Vs (vital signs) assessed. BP (blood pressure) 120/69 HR (heart rate) 88 RR (respiratory rate) 18." There was no documented evidence of which system was assessed to determine no apparent distress or injury. There was no documented evidence of a neurovascular assessment by the RN (fall was unwitnessed and patient found on floor disoriented).

In an interview on 03/20/17 at 4:12 p.m., S3LCSW confirmed the medical record of Patient R5 did not have documented evidence of a neurovascular assessment by the RN after an unwitnessed fall.

Altercation:
A request was made on 03/21/17 at 8:10 a.m. to S1ADM and 03/22/17 at 7:43 a.m. to S2IDON for a policy related to the RN's assessment of a patient after a fall or altercation. As of the time of exit on 03/22/17 at 3:40 p.m., no such policy was presented to the surveyor.

Patient R2
Review of the "Unusual Occurrence/Incident Report" documented by S28RN on 03/10/17 at 2:30 p.m. revealed that Patient R3 threw tea in Patient R2's face and Patient R2 struck Patient R3 in her chest. Further review revealed Patient R2 denied any injury or pain due to the "tea splash" and was assessed by S28RN and found without signs or symptoms of trauma.

Review of Patient R2's medical record revealed no documented evidence of documentation of the above incident. There was no documented evidence of the assessment that was documented by S28RN on the incident report that included what body part(s) was assessed to determine there was no "signs/symptoms of trauma."

Patient R3
Review of the "Unusual Occurrence/Incident Report" documented by S28RN on 03/10/17 at 2:30 p.m. revealed that Patient R3 threw tea on Patient R2, and Patient R2 struck Patient R3 in her chest. Patient R3 denied any pain at this time and was assessed by S28RN and found without physical signs or symptoms of trauma.

Review of Patient R3's "Daily Nursing Flowsheet" documented by S28RN on 03/10/17 at 2:25 p.m. revealed the same documentation as above in the incident report. There was no documented evidence of an assessment by S28RN of vital signs and what systems were assessed to determine that Patient R3 was without physical signs or symptoms of trauma.

In an interview on 03/20/17 at 3:57 p.m., S3LCSW confirmed the nursing note has no documented evidence of an assessment by S28RN other than "no trauma seen."

In an interview on 03/21/17 at 11:39 a.m., S17DON from a sister hospital indicated the RN should do a post fall assessment, and the fall should be added to the treatment plan. She further indicated the policy doesn't state that an assessment of all systems is required after a fall, but vital signs are required. She further indicated that she can't say that neurovascular checks are required unless they're ordered by the physician.

In an interview on 03/22/17 at 7:43 a.m., S2IDON indicated the nurse is supposed to do a post fall assessment.

4) The RN failed to assess and document the assessment of patients experiencing abnormal vital signs, abnormal capillary blood glucose (CBG) results, and a change in condition:
Review of the policy titled "Changes In Patient's Condition", presented as a current policy by S1ADM, revealed that the hospital has a process for recognizing and responding as soon as possible as a patient's condition appears to be worsening through daily nursing assessment and reassessment, vital signs, diagnostic testing, and visual observation of patient according to physician orders.

Review of the policy titled "Patient Assessment And Reassessment", presented as a current policy by S1ADM, revealed that each patient is reassessed as necessary based on his or her plan of care or changes in his or her condition.

Vital Signs:
Patient #3
Review of Patient #3's medical record revealed a physician's order dated 03/14/17 at 1:30 a.m. to do routine vital signs once per shift.

Review of patient #3's "Vital Signs" revealed the following documentation:
03/14/17 at 7:00 a.m. by S8MHT - BP 80/62; RR 148;
03/17/17 at 7:00 a.m. by S8MHT - BP 66/53; pulse 91;
03/18/17 at 4:26 a.m. by S9MHT - BP 67/43; pulse 106.

Review of Patient #3's medical record (contact notes and daily nursing flowsheet) revealed no documented evidence that the MHTs notified the RN of the abnormal VS and that an RN assessed Patient #3 at the time of the abnormal VS.

In an interview on 03/20/17 at 2:06 p.m., S3LCSW confirmed there was no documented evidence of an RN assessment of Patient #3's VS after the MHT documented the low BPs and elevated RR.

In an interview on 03/21/17 at 11:39 a.m., S17DON from a sister hospital indicated there should be documentation by the nurse of what was done to follow up on the abnormal VS on 03/14/17, 03/17/17, and 03/18/17. She further indicated the RN is supposed to review the VS taken by the MHTs, and the MHTs are supposed to give the VS to the nurse before the nurse passes medications.

CBG results:

Patient #8
Review of Patient #8's medical record revealed an admission date of 2/13/17 with an admission diagnosis of Unspecified psychosis and a co-morbid diagnosis of Diabetes Mellitus-Type II. Review of Patient #8's physician's orders, dated 2/13/17, revealed an order for accucheck 4 times/day. Additional review of Patient #8's medical record revealed the following nursing narrative note entries dated 02/13/17:
10:05 a.m. : Patient #8 came to have blood sugar checked. Accucheck read 538. Novolog 70/30 (insulin) 18 units and Nov R (insulin) 12 units. Notified S5MD.
11:05 Rechecked blood sugar, read 533. Notified NP. Ordered 12 Units of Nov R (insulin). Notified S5MD as well.
12:25 p.m. Recheck of blood sugar read 539. Nurse Practitioner notified. She spoke with S5MD and it was decided to send patient out to hospital.
2:05 p.m.: Ambulance called to take pt. to hospital.
3:50 p.m. Ambulance is leaving with patient now to take pt. to hospital.

Additional review of Patient #8's medical record revealed no documented evidence that another blood glucose level was assessed between 12:25 p.m. (time of last blood glucose level assessment) and 3:50 p.m. when the patient was transferred out via ambulance to receive evaluation and treatment at an area Acute Care Hospital.

Review of Patient #8's entire medical record revealed no documented evidence that Patient #8 had been assessed by a RN due to a change in condition (elevated blood glucose readings requiring transport to an Acute Care Hospital for evaluation and treatment) on 02/13/17.

In an interview on 3/21/17 at 10:13 a.m. with S12LPN she reported she had taken care of Patient #8 on 2/13/17. S12LPN indicated Patient #8 was supposed to be sent out to the hospital right away due to her elevated blood sugar. S12LPN confirmed there was a delay in transport of the patient. S12LPN also confirmed there was no documentation in the patient's chart of any further assessment of the patient's capillary blood glucose levels after the Accucheck performed on 2/13/17 at 12:25 p.m.(blood sugar result of 539). S12LPN indicated subsequent follow up capillary blood glucose assessments should have been performed. S12LPN also confirmed there was no insulin ordered/administered for the blood glucose of 539 at 12:25 p.m. S12LPN confirmed Patient #8 had not been assessed by the RN with the change in her condition. S12LPN said the NP was at the facility prior to the patient's transfer and she had been aware of the delay in transporting the patient.

5) The RN failed to ensure Accuchecks were assessed as ordered by the physician:
Review of Patient #3's medical record revealed a physician's order to perform Accuchecks ac and hs (before meals and at bedtime).

Review of Patient #3's documented Accuchecks revealed no documented evidence that Accuchecks were performed 4 times a day on 03/14/17, 03/15/17, 03/16/17, 03/17/17 and 03/18/17 as ordered. This was confirmed at the time of chart review by S3LCSW.

In an interview on 03/21/17 at 11:39 a.m., S17DON from a sister hospital indicated the expectation is that if Accuchecks were ordered at admit to be done ac and hs, there should be documentation of Accuchecks 4 times each day.


30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a comprehensive nursing care plan/treatment plan, inclusive of medical and psychological diagnoses, for 3 (#3, #5, #R7) of 6 (#1 - #5, R7) patients reviewed for the nursing care plan from a total sample of 14 patients and 10 random patients.
Findings:

Review of the policy titled "Plan Of Care", presented as a current policy by S1ADM, revealed that every patient shall have an individualized comprehensive plan of care. Every patient's plan of care shall identify patient goals and associated objectives and interventions necessary to meet the identified goals.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 03/13/17 with diagnoses of Major Depressive Disorder and Urinary Tract Infection. Review of Patient #3's nursing assessment documented by S7RN on 03/14/17 at 6:34 a.m. revealed previous medical problems included Type Diabetes, Hypertension, and Alzheimer's Disease. Review of the medical record revealed she had physician orders for Accuchecks 4 times a day (to monitor blood glucose), Aricept (used to treat mild to moderate dementia caused by Alzheimer's Disease), Hydrochlorothiazide (used to treat Hypertension), and Lisinopril (used to treat Hypertension). Review of the treatment plan revealed no documented evidence that Alzheimer's Disease, Type 2 Diabetes, and Hypertension were included in her care plan.

In an interview on 03/20/17 at 2:22 p.m., S3LCSW confirmed Patient #3's treatment plan did not include Alzheimer's Disease, Type 2 Diabetes, and Hypertension.

In an interview on 03/22/17 at 7:43 a.m., S2IDON confirmed Patient #3 should have been care planned for Alzheimer's Disease, Type 2 Diabetes, and Hypertension.

Patient #5
Review of Patient #5's medical record revealed an admission date of 03/04/17 with admission diagnoses including Schizoaffective Disorder, Bipolar Disorder, Viral Hepatitis C, and Epilepsy. Additional review revealed Patient #5 was being treated with Dilantin (anti-seizure medication) for seizures. Review of Patient #5's treatment plan revealed Viral Hepatitis C (a blood borne pathogen) and Epilepsy were not addressed as problems on the plan of care.

In an interview on 03/22/17 at 11:00 a.m. with S2IDON, she confirmed blood borne pathogen risk associated with Viral Hepatitis C and Epilepsy (seizure precautions) should have been addressed on Patient #5's treatment plan.

Patient R7
Review of Patient R7's medical record revealed an admission date of 07/10/16. Further review revealed Patient R7 was diagnosed with Scabies on admission. Additional review revealed Patient R7 was treated with Permetherine
(medication used to treat scabies) on 07/10/16. Review of Patient R7's treatment plan revealed Scabies had not been addressed as a problem on the patient's plan of care.

In an interview on 03/22/17 at 11:00 a.m. with S2IDON, she confirmed Scabies should have been addressed as a problem on Patient #R7's plan of care.


30984

Based on record review and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient in accordance with the patient's needs and the specialized qualifications and competence of the available nursing staff as evidenced by MHT assignments being made by the lead MHT rather than the RN.
Findings:

Review of the policy titled "Acuity Based Staffing", presented as a current policy by S1ADM, revealed that a core staffing pattern is utilized and adjusted every shift to meet patient and facility needs. The DON or designee will review acuity for the upcoming 24 hours. The characteristics of all patients will be considered including patient needs of the previous 24 hours, observation orders, number of precaution levels, and unit census.

In a telephone interview on 03/20/17 at 5:45 p.m., S24RN indicated on 03/19/17 for the night shift the lead MHT assigned 1 MHT to observe a patient on 1:1, 1 MHT to observe a patient on LOS, and 1 MHT to observe the other 16 patients. He further indicated the lead MHT made the assignments, and he signed the assignment sheet after he reviewed and approved the assignment.

In an interview on 03/20/17 at 6:05 p.m., S23MHT indicated the lead MHT makes the MHT assignments.

In a telephone interview on 03/21/17 at 9:20 a.m., S15RN indicated the lead MHT makes the MHT assignments.

In an interview on 03/22/17 at 7:43 a.m., S2IDON had no explanation when informed that multiple interviews revealed that the lead MHT was making MHT assignments rather than the RN.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice was evidenced by nursing staff administering insulin on two occasions without a physician's order for 1 (#7) of 4 (#3, #7, #8, #9) patients reviewed with insulin administration from a total sample of 14 patients and 10 random patients.
Findings:

Review of the hospital's policy titled Blood Glucose Monitoring, PC 14- Provision of Care, Treatment and Services, revealed in part:
Upon diagnosis of Hyperglycemia, insulin coverage shall be given only upon the order of physician, as either a one-time order or as a sliding scale based on the quantitative measure of glucose.

Review of Patient #7's medical record revealed an order dated 03/18/17 for blood glucose checks four times a day with meals. Further review revealed there was no physician's order for insulin administration.
Review of Patient #7's blood glucose log revealed documentation of 2 units of insulin having been administered on 03/19/17 and 03/20/17.

In an interview on 03/21/17 at 11:57 a.m. with S2IDON, she verified a nurse should not have administered insulin without a physician's order.

Based on observation, record reviews, and interviews, the hospital failed to ensure patients' medical records were accurately written and completed as evidenced by:
1) Failing to ensure patient observations by staff were conducted every 15 minutes as ordered by the physician for 3 (R8, R9, #10) of 3 patients observed on a hospital-provided video recording. The MHT failed to make observations as ordered every 15 minutes but documented that he did make the observations (as determined by viewing the hospital-provided video).
2) Failure to have patient observation forms completely documented for precaution type and observation level for 2 (#3, #9) of 6 (#1 - #5, #9) patient records reviewed for accurate and complete medical records from a total sample of 14 patients and 10 random patients.
Findings:

1) Failing to ensure patient observations by staff were conducted every 15 minutes as ordered by the physician with the MHT fraudulently documenting that the observations were made:
Observation on 03/20/17 at 4:00 p.m. with S1ADM of video surveillance of Hall A on the night of 03/19/17 and the morning of 03/20/17 revealed neither S23MHT nor any other staff member conducted the physician-ordered every 15 minute observations on Patient R8, Patient R9 or Patient #10 from 5:00 a.m. until 7:00 a.m. (2 hours).

Review of a hospital provided list of patients and diagnosis revealed the following:
Patient R8 had been admitted on 03/17/17 with diagnoses including Bipolar Disorder Unspecified and Alcohol Abuse. Patient R9 had been admitted on 03/12/17 with a diagnosis of Recurrent Major Depressive Disorder. Patient #10 had been admitted on 03/07/17 with a diagnosis of Altered Mental Status.

Review of the 15 minute observation sheets revealed S23MHT had initialed on 03/20/17 from 5:00 a.m. through 6:45 a.m. that he had observed Patients R8, R9 and Patient #10 every 15 minutes.

In an interview on 03/20/17 at 4:30 p.m. with S1ADM, he verified S23MHT did not observe Patients R9, R8 or #10 every 15 minutes as ordered by the physician. He also verified S23MHT had documented on the patients' observation sheets that he had observed the patients every 15 minutes although he had not.

In an interview on 03/20/17 at 6:05 p.m., S23MHT indicated he worked the night shift on 03/19/17 (7:00 p.m. to 7:00 a.m. on 03/20/17). When informed that observation of the hospital-provided video by the surveyor with S1ADM present revealed no observation of any staff member in the hall on 03/20/17 between 5:00 a.m. and 7:00 a.m., S23MHT indicated he missed some every 15 minute observations while he was doing some of the assigned MHT duties such as getting all patients up and having them go to the day room at 6:00 a.m., making sure the shower is clean, taking the dirty linen to the laundry (located in the adjacent nursing home), collecting all trash, taking the coolers to be sterilized to the dietary department in the adjacent nursing home, making the tea and lemonade, and taking the dietary sheets to the dietary department in the adjacent nursing home. S23MHT confirmed he documented that he made the observations, but he did not actually make the observations. When asked if he was aware that this was fraudulent documentation, he answered "yes."

2) Failure to have patient observation forms completely documented for precaution type and observation level:
Patient #3
Review of Patient #3's physician orders dated 03/14/17 at 1:30 a.m. revealed orders for aggression precautions until discontinued by the psychiatrist, fall precautions until discontinued by psychiatrist, and every 15 minute check unless increased by order from psychiatrist. Further review revealed an order on 03/17/17 at 4:07 p.m. for LOS every day. There was no physician order to discontinue fall and aggression precautions.

Review of Patient #3's "Q (every) 15 minute Close Observation Form" for 03/15/17, 03/16/17, and 03/19/17 revealed no documented evidenced that fall precautions were checked. Further review revealed no documented evidence that aggression precautions was added to the forms on 03/15/17, 03/16/17, 03/17/17, and 03/19/17. Further review revealed no documented evidence that the level of observation was documented on 03/13/17 (upon admit) , 03/16/17,and 03/17/17 from 7:00 a.m. to 2:45 p.m.

Patient #9:
Review of the medical record revealed the patient was admitted to the hospital on 03/16/17. The patient had the diagnoses of Disorganized Schizophrenia and Psychosis.

Review of the Coroner's Emergency Certificate dated 03/16/17 revealed the boxes for dangerous to self, dangerous to others, gravely disabled, and unable to seek voluntary admission were checked.

Review of Q 15 Minute Close Observation Forms dated 03/16/17, 03/17/17, 03/18/17, and 03/19/17 revealed the Precaution Type box was not checked.

Review of Q 15 Minute Close Observation Forms dated 03/16/17 and 03/17/17 revealed the Observation Level box was not checked.

In an interview on 03/22/17 at 10:01 a.m., S19COO indicated staff should check the appropriate box for precaution type and observation level on the close observation forms.



25065




30984

Based on record review and interview, the hospital failed to ensure the UR (Utilization Review) committee was comprised of two or more doctors of medicine or osteopathy who were not professionally involved in the care of the patients whose cases were being reviewed as evidenced by having S4Psych and S5MD as the 2 physician members, both of whom manage patient care at the hospital.
Findings:

Review of the Utilization Management Plan, presented as current by S26UR, revealed in part: Conflict of Interest: Physicians may not participate in the review of any cases in which he/she has been or anticipates being professionally involved.

In an interview on 03/22/17 at 12:47 p.m. with S26UR, she indicated the two physician members of the UR committee were S4Psych and S5MD. She confirmed both physicians managed care of the hospital's patients.

Based on observation, record review, and interview, the hospital failed to ensure the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) Failure to ensure infection control practices were followed during blood drawing for 1 (#1) of 2 (#1, R10) patients observed for staff adherence to infection control principles during performance of invasive procedures;
2) Failure to monitor contracted lab technicians' adherence to infection control practices during patient blood draws; 3) Failure to collect and assimilate staff and patient infection control data for February 2017 through 03/22/2017; and
4) Failure to ensure a patient (R7) with a diagnosis of scabies was placed on contact isolation precautions.
Findings:

1) Failure to ensure infection control practices were followed during blood drawing:
On 03/21/17 at 7:35 a.m., an observation was made of S20LabTech (contracted phlebotomist) attempting to draw blood via venipuncture on Patient #1. The blood collection tubes were noted to be placed on the lab request sheet, which was on the floor. The blood collection supply case was also observed on the floor of the patient's room. S20LabTech was wearing gloves and was observed touching the patient's bedding and clothing with her gloved hands. She repositioned the patient, changed her gloves without performing hand hygiene, and placed the used gloves on the patient's bed. She donned a new pair of gloves without performing hand hygiene with the glove change. S20LabTech then drew the patient's blood. She touched the supply box with her gloved hands, then removed the gloves, again without performing hand hygiene. S20LabTech also failed to disinfect the handle, top, and bottom of the blood collection supply case.

Review of the hospital's policy titled, Infection Prevention and Control Plan, Policy Number: IC 15, revealed in part:
Purpose: 1. This hospital provides guidelines for interaction between patients and healthcare providers to prevent the transmission of infectious agents associated with healthcare.
Standard Precautions: combine the features of universal precautions and body substance isolation. Standard precautions apply to all patients regardless of their diagnosis or suspected infection status. Standard precautions apply to the following: Blood, all body fluids, excretions, secretions, except sweat, whether or not they contain visible blood, non-intact skin and mucous membranes. Standard precautions include hand hygiene; personal protective equipment: Gloves: Are to be worn when touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin and other contaminated items such as equipment. Hands are to be washed before and after removing gloves. Gloves are changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.

In an interview on 03/21/17 at 7:50 a.m. with S20LabTech, she indicated she was from the contracted lab service and was not directly employed by the hospital. S20LabTech indicated she had been taught to perform hand hygiene between patients and said Patient #1 was the only patient getting blood drawn. S20LabTech also indicated the blood draw supply case was wiped down/cleaned once a week.

In an interview on 03/22/17 at 10:50 a.m. with S2IDON, she was informed of the above-referenced infection control breaches noted during an observation of S20LabTech on 03/22/17 at 7:20 a.m. while she was performing Patient #1's venipuncture. S2IDON confirmed hand hygiene should have been performed between glove changes. She also agreed the blood tubes/collection supply case should have placed somewhere other than on the floor. S2IDON also agreed the supply case should have been disinfected after use.

2) Failure to monitor contracted lab technician's adherence to infection control practices during patient blood draws:
Review of the infection control documentation, presented as current by S2IDON, revealed no documented evidence of monitoring of contracted lab technicians' adherence to infection control practices during performance of invasive procedures.

In an interview on 03/22/17 at 10:50 a.m. with S2IDON, she was informed of the infection control breaches (referenced above) noted during the observation of S20LabTech performing venipuncture on Patient #1 on 03/22/17 at 7:20 a.m. S2IDON confirmed observation of lab technician technique during performance of venipuncture was not included in the hospital's infection control surveillance.

3) Failure to collect and assimilate staff and patient infection control data for 2/2017 through 3/22/17:
Review of the infection control documentation, presented as current by S2IDON, revealed no documented evidence that staff and patient infection control data had been collected and assimilated from February 2017 through 03/22/2017.

In an interview on 03/22/17 at 10:50 a.m. with S2IDON, she confirmed there was no documented evidence that staff and patient infection control data had been collected and assimilated from February 2017 through 03/22/17. S2IDON indicated the former DON had been the Infection Control Officer, and she had recently left the position.

4) Failure to ensure a patient (R7) with a diagnosis of scabies was placed on contact isolation precautions:
Review of Patient R7's medical record revealed an admission date of 07/10/16. Further review revealed Patient R7 was diagnosed with Scabies on admission. Additional review revealed Patient R7 was treated with Permetherine (medication used to treat scabies) on 07/10/16. Patient R7's entire medical record was reviewed, and no documented evidence was found to indicate the patient had been placed on contact isolation precautions.

In an interview on 03/22/17 at 11:00 a.m. with S2IDON, she confirmed, after review of Patient R7's medical record, that there was no documented evidence that the patient had been placed on contact precautions for his diagnosis of Scabies. She indicated patients with Scabies are placed on contact isolation precautions for at least 24 hours during treatment, and sometimes longer, depending upon whether treatment was successful.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of participation for Discharge Planning as evidenced by:

1) Failing to ensure a consistent system was developed and implemented for identifying at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning as evidenced by having no documented evidence of the process for assessing the continuing care needs of 3 (#10, #12, #13) of 3 patient records reviewed for discharge planning from a total sample of 14 patients and 10 random patients. (see findings in tag A0800).

2) Failing to ensure the patient's discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital as evidenced by failure to have documented evidence of such evaluations for 3 (#10, #12, #13) of 3 patient records reviewed for discharge planning from a total sample of 14 patients and 10 random patients (see findings in tag A0806).

3) Failing to ensure the hospital arranged for the implementation of the patient's discharge plan that included counseling the patient and/or family members to prepare them for post-hospital care as evidenced by failure of the hospital to provide a list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's admission medications for 3 (#10, #12, #13) of 3 patient records reviewed for discharge planning from a total sample of 14 patients and 10 random patients (see findings in tag A0820).

Based on record reviews and interviews, the hospital failed to ensure a consistent system was developed and implemented for identifying at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning as evidenced by having no documented evidence of the process for assessing the continuing care needs of 3 (#10, #12, #13) of 3 patient records reviewed for discharge planning from a total sample of 14 patients and 10 random patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that discharge planning identified a process and service where patient needs are identified and evaluated. Each patient's needs for continuing care are assessed in an ongoing fashion by all members of the healthcare team. This assessment may begin prior to admission, but in no event later than at the time of the admission nursing assessment.

Review of the policy titled "Addressing Patient Needs For Continuing Care, Treatment And Services After Discharge Or Transfer", presented as a current policy by S1ADM, revealed that the hospital has a process that addresses the patient's need for continuing care, treatment, and services after discharge or transfer. The policy included that when the discharge planning evaluation indicated the need for home health care or post hospital extended care services, the discharge plan would include a list of participating providers of such care. Review of the entire policy revealed no documented evidence that the policy addressed the specific process for addressing the patient's need for continuing care, treatment, and services after discharge or transfer. The hospital presented no documented evidence of a discharge planning evaluation used to determine the need for continuing care, treatment, and services after discharge or transfer.

Review of the policy titled "Social Services/Discharge Planning Screening", presented as a current policy by S1ADM, revealed that the hospital identifies patient discharge needs upon admission and provides appropriate discharge planning interventions according to the patient's multidisciplinary plan of care. Further review revealed that patients who may require more complex discharge planning include patients living alone or with a non-capable caregiver; individuals of all ages who are admitted from, or anticipate being transferred to, nursing homes, residential care homes, or specialty hospital; unclear or no known place of residence "("street people", indigent, abandoned)".

Review of the "Psychosocial Assessment" revealed a question asks the person's living situation, whether the patient is at risk of losing current housing, and whether the patient is satisfied with the current living situation.

Review of the "Initial Psychiatric Evaluation" revealed a question asks the person's living situation, whether the patient is at risk of losing current housing, and whether the patient is satisfied with the current living situation.

Review of the "Nursing Assessment" revealed no documented evidence that the initial nursing assessment included a section on discharge planning.

In an interview on 03/22/17 at 8:55 a.m. with S3LCSW and S11LCSW present, S3LCSW indicated once all assessments are completed, the assessments and the psychiatric evaluation are used to determine the criteria for discharge. S11LCSW indicated they have a framework of criteria for discharge planning, but they don't have specific tool to use to conduct a discharge planning evaluation. She further indicated after admit, the social service staff meets with the patient to obtain the following information: current outpatient psychiatric care; obtain information from family if necessary; assess the living situation; see if the staff has to work on any housing supportive services needed; include questions about transportation needed at discharge; where the patient obtains medications and if they have access to medications that are needed. She further indicated this information should be documented in contact notes in the patient's medical record.

Patient #10
Review of Patient #10's medical record revealed he was admitted on 03/07/17 and discharged on 03/20/17. Review of his contact notes revealed a note documented by S11LCSW on 03/16/17 at 12:00 p.m. revealed that Patient 310's cousin requested information regarding medication changes, and S11LCSW told the cousin that she would have the nursing staff call him with the requested information. Review of all documentation from the time of S11LCSW's conversation with Patient #10's cousin until his discharge on 03/20/17 revealed no documented evidence that a nurse had contacted the cousin to inform him of the requested medication information.

Review of Patient #10's medical record revealed he was admitted from a nursing home, was single, and had no children. There was no documented evidence an assessment of whether Patient #10 would be allowed to return to the nursing home and whether the care he required would be able to be provided at the nursing home. There was no documented evidence of communication by the social service department staff with the nursing home.

In an interview on 03/21/17 at 2:20 p.m., S17DON indicated all patients are assigned a social worker who is responsible for discharge planning. She further indicated the hospital has no form or evaluation tool used for discharge planning.

In an interview on 03/22/17 at 9:19 a.m. with S3LCSW and S11LCSW present, S11LCSW indicated the psychosocial assessment assesses the current living situation. She further indicated that Patient #10's discharge/transition summary included that he lived in the nursing home. She confirmed that there should be documentation in the patient's medical record that the assessment determined that a patient can return to their prior living environment from which they were admitted. She further indicated the discharge planning evaluation "falls on the social service department. S11LCSW indicated the discharge planning assessment is "in place but not always documented and done."

Patient #12
Review of Patient #12's medical record revealed she was admitted on 02/11/17 and discharged on 02/21/17. Further review revealed she lived alone in a rental apartment. Review of the medical record revealed no documented evidence of the location to which she was discharged, any discharge planning evaluations by hospital staff, and neither hospital staff or the patient signed her discharge instructions.

In an interview on 03/22/17 at 9:27 a.m. with S3LCSW and S11LCSW present, S11LCSW indicated the medical record had no documented contact notes related to discharge planning.

Patient #13
Review of Patient #13's medical record revealed he was admitted on 02/15/17 and discharged on 03/03/17. Review of his psychosocial assessment revealed he was homeless and resided in a shelter. Review of his entire medical record revealed no documented evidence of contact notes or any documentation by the social service staff related to discharge planning. Review of his discharge instructions revealed no documented evidence of the destination to which Patient #13 was discharged.

In an interview on 03/22/17 at 9:07 a.m. with S3LCSW and S11LCSW present, S11LCSW indicated there should be some documented attempt to contact family within 24 hours of his admission. She further indicated there should have been some documentation of attempts to locate housing, and housing should have been identified as a problem.

Based on record reviews and interviews, the hospital failed to ensure the patient's discharge planning evaluation included an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services and an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital as evidenced by failure to have documented evidence of such evaluations for 3 (#10, #12, #13) of 3 patient records reviewed for discharge planning from a total sample of 14 patients and 10 random patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that discharge planning identified a process and service where patient needs are identified and evaluated. Each patient's needs for continuing care are assessed in an ongoing fashion by all members of the healthcare team. This assessment may begin prior to admission, but in no event later than at the time of the admission nursing assessment.

Review of the policy titled "Addressing Patient Needs For Continuing Care, Treatment And Services After Discharge Or Transfer", presented as a current policy by S1ADM, revealed that the hospital has a process that addresses the patient's need for continuing care, treatment, and services after discharge or transfer. The policy included that when the discharge planning evaluation indicated the need for home health care or post hospital extended care services, the discharge plan would include a list of participating providers of such care. Review of the entire policy revealed no documented evidence that the policy addressed the specific process for addressing the patient's need for continuing care, treatment, and services after discharge or transfer. The hospital presented no documented evidence of a discharge planning evaluation used to determine the need for continuing care, treatment, and services after discharge or transfer.

Review of the policy titled "Social Services/Discharge Planning Screening", presented as a current policy by S1ADM, revealed that the hospital identifies patient discharge needs upon admission and provides appropriate discharge planning interventions according to the patient's multidisciplinary plan of care. Further review revealed that patients who may require more complex discharge planning include patients living alone or with a non-capable caregiver; individuals of all ages who are admitted from, or anticipate being transferred to, nursing homes, residential care homes, or specialty hospital; unclear or no known place of residence "("street people", indigent, abandoned)".

Review of the "Psychosocial Assessment" revealed a question asks the person's living situation, whether the patient is at risk of losing current housing, and whether the patient is satisfied with the current living situation. There is no documented evidence that the assessment evaluates whether the patient can return to the prior living environment; whether environmental changes are needed to the prior living environment in order for the patient to be able to return; and whether the patient is able to provide his/her own care, and if not, whether there is a capable and willing caregiver to provide the needed care.

Review of the "Initial Psychiatric Evaluation" revealed a question asks the person's living situation, whether the patient is at risk of losing current housing, and whether the patient is satisfied with the current living situation.

Review of the "Nursing Assessment" revealed no documented evidence that the initial nursing assessment included a section on discharge planning.

Patient #10
Review of Patient #10's medical record revealed he was admitted on 03/07/17 and discharged on 03/20/17. Review of his contact notes revealed a note documented by S11LCSW on 03/16/17 at 12:00 p.m. revealed that Patient #10's cousin requested information regarding medication changes, and S11LCSW told the cousin that she would have the nursing staff call him with the requested information. Review of all documentation from the time of S11LCSW's conversation with Patient #10's cousin until his discharge on 03/20/17 revealed no documented evidence that a nurse had contacted the cousin to inform him of the requested medication information.

Review of Patient #10's medical record revealed he was admitted from a nursing home, was single, and had no children. There was no documented evidence an assessment of whether Patient #10 would be allowed to return to the nursing home and whether the care he required would be able to be provided at the nursing home. There was no documented evidence of communication by the social service department staff with the nursing home.

In an interview on 03/21/17 at 2:20 p.m., S17DON indicated all patients are assigned a social worker who is responsible for discharge planning. She further indicated the hospital has no form or evaluation tool used for discharge planning.

In an interview on 03/22/17 at 9:19 a.m. with S3LCSW and S11LCSW present, S11LCSW indicated the psychosocial assessment assesses the current living situation. She further indicated that Patient #10's discharge/transition summary included that he lived in the nursing home. She confirmed that there should be documentation in the patient's medical record that the assessment determined that a patient can return to their prior living environment from which they were admitted. She further indicated the discharge planning evaluation "falls on the social service department. S11LCSW indicated the discharge planning assessment is "in place but not always documented and done."

Patient #12
Review of Patient #12's medical record revealed she was admitted on 02/11/17 and discharged on 02/21/17. Further review revealed she lived alone in a rental apartment. Review of the entire medical record revealed no documented evidence of an assessment by hospital staff of whether she could return to living alone, whether she could provider her own care, and if not, whether there was a capable and willing caregiver available to provide her care, and whether any environmental changes were required in order for her to return to her prior living environment. Review of the medical record revealed no documented evidence of the location to which she was discharged, any discharge planning assessments by hospital staff, and neither hospital staff or the patient signed her discharge instructions.

In an interview on 03/22/17 at 9:27 a.m. with S3LCSW and S11LCSW present, S11LCSW indicated the medical record had no documented contact notes related to discharge planning.

Patient #13
Review of Patient #13's medical record revealed he was admitted on 02/15/17 and discharged on 03/03/17. Review of his psychosocial assessment revealed he was homeless and resided in a shelter. Review of his entire medical record revealed no documented evidence of contact notes or any documentation by the social service staff related to discharge planning. Review of his discharge instructions revealed no documented evidence of the destination to which Patient #13 was discharged.

In an interview on 03/22/17 at 9:07 a.m. with S3LCSW and S11LCSW present, S11LCSW indicated there should be some documented attempt to contact family within 24 hours of his admission. She further indicated there should have been some documentation of attempts to locate housing, and housing should have been identified as a problem.

Based on record reviews and interviews, the hospital failed to ensure the hospital arranged for the implementation of the patient's discharge plan that included counseling the patient and/or family members to prepare them for post-hospital care as evidenced by failure of the hospital to provide a list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's admission medications for 3 (#10, #12, #13) of 3 patient records reviewed for discharge planning from a total sample of 14 patients and 10 random patients.
Findings:

Review of the policy titled "Discharge Planning", "Addressing Patient Needs For Continuing Care, Treatment And Services After Discharge Or Transfer", and "Social Services/Discharge Planning Screening", all presented as a current policy by S1ADM, revealed no documented evidence that any of the policies addressed the process for counseling patients and/or family members and providing them with a list of all medications the patient should be taking after discharge, with clear indication of changes from the patient's admission medications.

Review of the medical records of Patients #10, #12, and #13 revealed each was provided a list of medications each patient was to take after discharge. There was no documented evidence that the list included a clear indication of the changes in the medications prescribed at discharge from those the patient was taking at the time of admission.

In an interview on 03/22/17 at 9:07 a.m. with S3LCSW and S11LCSW present, S11LCSW confirmed the patient does not receive a medication reconciliation list that clearly shows the changes to medications prescribed at discharge from those the patient was taking prior to admission.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of 482.13 (Patient Rights) and 482.23 (Nursing Services) as evidenced by:

1) Failing to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:
a) Failing to ensure patient observations were conducted by staff every 15 minutes as ordered by the physician for 3 (#R8, #R9, #10) of 3 patients observed on a hospital-provided video recording (see findings tag A-0144); and

b) Failing to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment was completed for 3 (#3, #11, #14) of 7 (#1 - #5, #11, #14) patient records reviewed for accurate observation levels from a total of 14 sampled patients and 10 random patients (see findings tag A-0144).

2) Failing to meet the requirements of the Condition of Participation for Nursing services as evidenced by:
a) Failing to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:
(1) The RN failed to ensure observations were made by the MHT as ordered by the psychiatrist on the night shift of 03/19/17.
(2) The RN failed to ensure patients were observed in accordance with hospital policy (related to suicide/homicide risk assessments) when admitted with a suicide or homicide attempt or until the suicide/homicide risk assessment was completed for 3 (#3, #11, #14) of 3 patient records reviewed for accurate observation levels from a total of 14 sampled patients and 10 random patients.
(3) The RN failed assess patients and document the assessment after a fall (#3, R4, R5) and after an altercation (R2, R3) for 5 (#3, R2, R3, R4, R5) of 5 patient records reviewed for an RN assessment of a patient after a fall or altercation from a total of 14 sampled patients and 10 random patients.
(4) The RN failed to assess and document the assessment of patients experiencing abnormal vital signs (#3), abnormal capillary blood glucose results (#8), and a change in condition (#8, R5) for 3 (#3, #8, R5) of 7 (#1 - #5, #8, R5) patient records reviewed for RN assessment from a total of 14 sampled patients and 10 random patients.
(5) The RN failed to ensure Accuchecks (capillary blood glucose checks) were assessed as ordered by the physician for 1 (#3) of 4 (#3, #7, #8, #9) diabetic patient records reviewed for Accuchecks from a total of 14 sampled patients and 10 random patients (see findings in tag A0395).

b) Failing to ensure there was a plan for administrative authority for nursing services to ensure the nursing services was under the direction of one RN employed by the hospital in the absence of the DON as evidenced by having coverage for nursing services provided by DONs from other sister hospitals on the weekend of 03/18/17 and 03/19/17 and on 03/21/17 (see findings in tag A0386).

30984

Based on record review and interview, the hospital failed to ensure the specific treatment modalities utilized for the patients were named in the treatment plans as evidenced by failure to address each ordered treatment modality on the master treatment plan for 3 (#3, #5, #11) of 7 (#1 - #5, #11, R7) patient records reviewed for treatment plans from a total sample of 14 patients and 10 random patients.
Findings:

Review of the hospital policy titled "Plan Of care - Protocol For The Use Of Multidisciplinary Format", presented as a current policy by S1ADM, revealed that the multidisciplinary plan of care format includes a problem-specific plan of care which includes treatment interventions that are specific to the objectives, indicated the frequency of provision, and the discipline/staff responsible.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 03/13/17 with diagnoses of Urinary Tract Infection and Major depressive Disorder. She was PEC'd on 03/13/17 at 2:55 p.m. due to having a history of Alzheimer's, aggressive towards nursing home staff, violent, and a danger to self and others. She was CEC'd (Coroner's Emergency Certificate) on 03/14/17 at 2:05 p.m. due to having a history of Alzheimer's, worsening aggression and combative behavior, and being a danger to self.

Review of Patient #3's physician orders revealed orders for nursing education group to be done daily, individual psychotherapy to be done as needed, group psychotherapy to be done daily, and activity group to be done daily.

Review of Patient #3's treatment plan revealed group psychotherapy was to be done for 45 minutes to explore insight and increase coping, life skills, and rational thoughts. There was no documented evidence of the frequency the group was to be conducted. Further review revealed no documented evidence that nursing education group, individual psychotherapy, and activity group were included in her treatment plan.

Patient #5
Review of Patient #5's medical record revealed an admission date of 03/04/17 with an admission diagnosis of Schizoaffective Disorder.

Review of Patient #5's Physician admission orders, dated 03/04/17, revealed an order for
Activity Therapy; Frequency: every day; Start date: 03/04/17.

Review of Patient #5's current Treatment Plan revealed no documented evidence that the ordered daily Activity Therapy was addressed on the patient's treatment plan.

Patient #11
Review of Patient #11's medical record revealed an admission date of 03/11/17 at 1:30 p.m. with an admission diagnosis of Bipolar Disorder, manic with severe Psychosis. Further review revealed the patient was PEC'd on 03/12/17 at 10:54 a.m. due to being suicidal at the time of the PEC and being dangerous to self, gravely disabled and unwilling to seek voluntary admission.

Review of Patient #11's admission orders, dated 03/11/17, revealed an order for
Nursing Education Group; Frequency: every day; Start date: 03/12/17

Review of Patient #11's current Treatment Plan revealed the ordered daily Nursing Education Group Therapy was not addressed in the patient's treatment plan.

In an interview on 03/21/17 at 2:00 p.m. with S21SW, she confirmed ordered treatment modalities and the staff responsible for the therapy groups should be documented on the patients' treatment plans.

30984

Based on record review and interview, the hospital failed to ensure the patients' written treatment plans included the responsibilities of each member of the treatment team. This deficient practice was evidenced by failure of the hospital to ensure the staff responsible for each therapy group was documented on the patients' treatment plans for 3 (#3, #5, #11, #R7) of 7 (#1 - #5, #11, R7) patients' records reviewed for treatment planning from a total sample of 14 patients and 10 random patients.
Findings:

Review of the hospital policy titled "Plan Of care - Protocol For The Use Of Multidisciplinary Format", presented as a current policy by S1ADM, revealed that the multidisciplinary plan of care format includes a problem-specific plan of care which includes treatment interventions that are specific to the objectives, indicated the frequency of provision, and the discipline/staff responsible.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 03/13/17 with diagnoses of Urinary Tract Infection and Major depressive Disorder. She was PEC'd on 03/13/17 at 2:55 p.m. due to having a history of Alzheimer's, aggressive towards nursing home staff, violent, and a danger to self and others. She was CEC'd (Coroner's Emergency Certificate) on 03/14/17 at 2:05 p.m. due to having a history of Alzheimer's, worsening aggression and combative behavior, and being a danger to self.

Review of Patient #3's physician orders revealed orders for nursing education group to be done daily, individual psychotherapy to be done as needed, group psychotherapy to be done daily, and activity group to be done daily.

Review of Patient #3's treatment plan revealed group psychotherapy was to be done for 45 minutes to explore insight and increase coping, life skills, and rational thoughts. There was no documented evidence of the frequency the group was to be conducted and the discipline/staff responsible for conducting the group. Further review revealed no documented evidence that nursing education group, individual psychotherapy, and activity group were included in her treatment plan with the discipline/staff responsible for each group.

Patient #5
Review of Patient #5's medical record revealed an admission date of 03/04/17 with an admission diagnosis of Schizoaffective Disorder. Patient #5's legal status was PEC'd (03/04/17) due to being violent, and dangerous to self, dangerous to others, and unwilling/unable to seek voluntary admission and CEC'd (03/06/17) due to being dangerous to self, to others, gravely disabled and unable to seek voluntary admission.

Review of Patient #5's admit physician orders, dated 03/04/17, revealed an order for Activity Therapy; Frequency: every day; Start date: 03/04/17.

Review of Patient #5's current Treatment Plan revealed no documented evidence that the ordered daily Activity Therapy was addressed on the patient's treatment plan. Further review revealed no specific staff member was documented as being the staff member as being responsible for conducting the ordered daily Activity Therapy Groups.

Patient #11
Review of Patient #11's medical record revealed an admission date of 03/11/17 at 1:30 p.m. with an admission diagnosis of Bipolar Disorder, manic with severe Psychosis. Further review revealed the patient was PEC'd on 03/12/17 at 10:54 a.m., due to being suicidal at the time of the PEC and dangerous to self, gravely disabled and unwilling to seek voluntary admission.

Review of Patient #11's admit physician orders, dated 03/11/17, revealed the following orders for therapy:
Activity Therapy; Frequency: every day; Start date: 03/12/17
Group Psychotherapy; Frequency: every day; Start date: 03/12/17
Nursing Education Group; Frequency: every day; Start date: 03/12/17

Review of Patient #11's current Treatment Plan revealed the following, in part:
Plan: Maladaptive Cognition: Develop healthy cognitive patterns and beliefs about self and world that help alleviate depressed feelings. Re-establish sense of hope for self and for the future. Provider: Activity Group. Further review revealed no specific staff member was documented as being responsible for conducting the ordered daily Activity Therapy Groups.

Anger Management: Develop skills to deal with uncomfortable emotions and feelings in such a way as not to violate the personal rights of others and return to previous level of functioning. Provider: Group Psychotherapy (45 minutes) to explore insight and increase coping, life skills and rationale thoughts. Further review revealed no specific staff member was documented as being responsible for conducting the ordered daily Psychotherapy Group.

Thoughts of self harming: Improve symptomatology and functioning to the degree that patient is no longer a threat to self and others.
Develop a crisis safety plan identifying 3 problematic situations, 3 triggers, and 3 coping skills in 5 days.
Provider: Group Psychotherapy (45 minutes) to explore insight and increase coping, life skills and rationale thoughts. Further review revealed no specific staff member was documented as being responsible for conducting the ordered daily Psychotherapy Group.

Patient R7
Review of Patient R7's medical record revealed an admission date of 07/10/16 with an admission diagnosis of Schizoaffective Disorder, Bipolar type. Patient #R7's legal status was CEC'd on admission.

Review of Patient R7's Treatment Plan revealed the following, in part:
Plan: Altered thought process: Control or eliminate active psychotic symptoms so that supervised functioning is positive and medication is taken consistently. Increase goal directed behavior. Comply with psychotropic medication regimen. Provider: Activity Group. Further review revealed no documented evidence that a specific assigned staff member was responsible for conducting the Activity Therapy Group and the Group Psychotherapy addressed on the patient's treatment plan.

In an interview on 03/21/17 at 2:00 p.m. with S21SW, she confirmed treatment modalities and the staff responsible for the therapy groups should be documented on the patients' treatment plans.

30364


Based on record review and interview, the hospital failed to ensure progress notes were written to demonstrate involvement of the patient in physician-ordered group therapies or reasons for the patient not attending the group therapies for 2 (#3, #7) of 6 (#1 - #5, #7) patient records reviewed for documentation of progress notes related to patients' attendance at group therapy from a total sample of 14 patients and 10 random patients.
Findings:

Patient #3
Review of Patient #3's medical record revealed she was admitted on 03/13/17 with diagnoses of Urinary Tract Infection and Major depressive Disorder. She was PEC'd on 03/13/17 at 2:55 p.m. due to having a history of Alzheimer's, aggressive towards nursing home staff, violent, and a danger to self and others. She was CEC'd (Coroner's Emergency Certificate) on 03/14/17 at 2:05 p.m. due to having a history of Alzheimer's, worsening aggression and combative behavior, and being a danger to self.

Review of Patient #3's physician orders revealed orders for nursing education group to be done daily, individual psychotherapy to be done as needed, group psychotherapy to be done daily, and activity group to be done daily.

Review of Patient #3's progress notes revealed no documented evidence that she attended the following groups on the respective dates or the reason why she did not attend: nursing group on 03/14/17, 03/15/17, 03/16/17, 03/17/17, 03/19/17; social work group on 03/14/17, 03/15/17, 03/16/17, 03/18/17, and activity group on 03/16/17, 03/17/17, 03/18/17, 03/19/17/

Patient #7
Review of Patient #7's medical record revealed she had physician's orders dated 03/18/17 for nursing and social work group daily. There was no documented evidence of Patient #7 attending the nursing or social work groups or why she was unable to attend the groups on 03/19/17 or 03/20/17.

In an interview on 03/22/17 at 8:15 a.m. with S2IDON, she verified documentation should have been in patients' medical records about their attendance in groups or the reason why they could not attend group.