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Based on record review and interview, the hospital failed to meet the Condition of Participation for Patient's Rights as evidenced by:
1) Failing to ensure care in a Safe Setting as evidenced by Patient #10 physically striking four patients. 4 of 4 patients (#11, #12, #15, #22) were physically struck by Patient #10 and required medical intervention.
2) Failing to ensure care if safe setting by failing to ensure the RN assessed patients exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff from injury for 3 of 4 patients reviewed who were exhibiting behaviors of aggression and and sexually inappropriate behavior from a total sample of 22 patients (#19, #20, #21). Findings:
An Immediate Jeopardy situation was identified on 10/20/11 at 3:00 p.m. and reported to S2 Vice-President of Patient Care Services. The Immediate Jeopardy situation was a result of the following:
The hospital failed to ensure the patient's Right to Care in a Safe Setting as evidenced by Patient #10 physically striking four patients. 4 of 4 patients (#11, #12, #15, #22) physically struck by Patient #10 required medical intervention. On the following dates, Patient #10 exhibited the following: 09/24/11 struck Patient #11 who suffered bleeding from the nose and mouth and required a facial x-ray; 09/26/11 struck Patient #12 who had an abrasion to the forehead and required a Computerized Tomography (CT) scan; 10/02/11 struck Patient #22 who had redness and swelling and required a facial x-ray; 10/09/11 struck Patient #15 and grabbed him around the neck that resulted in the need for a CT scan.
Patient #10 was admitted under Physician Emergency Certificate on 09/23/11 at 1800 (6:00pm) as a danger to others. There was no effective therapeutic intervention implemented after the initial occurrence of striking a patient to prevent continued events of aggression upon other patients. The hospital had no organized system for implementing measures, other than providing increased level of monitoring, to ensure all patients were safe from a patient with a history of physical aggression and/or who was assaulting other patients. There was no documented evidence that a plan of care was developed and implemented with goals identified to address the potential for injury to others.
Review of inpatients currently on the acute behavioral unit (Patients #19, #20, #21) with documented evidence for the potential of exhibiting physical aggression and sexually-inappropriate behavior revealed no documented evidence that nursing interventions and goals were identified and implemented to address aggressive and sexually-inappropriate behavior.
A corrective action plan was submitted by the hospital on 10/21/11 at 4:50pm to address the immediate jeopardy situation. The corrective action plan included the following:
1) Immediately assess to ensure Patients #19, #20, and #21, with documented evidence for the potential of exhibiting physical aggression and sexually-inappropriate behavior, had the injury risk care plan with nursing interventions and goals to address aggressive and sexually-inappropriate behavior added to their plan of care;
2) Medical Doctor (MD) to review of each of these patients and order appropriate measures such as distance, restraints, seclusion, as appropriate to policy;
3) MD review of all patients on the acute behavioral unit and indicate whether the patient was a danger to others and add appropriate care plan of risk to others and any other appropriate MD orders;
4) Educate current staff on duty about patient rights and the protection of patients from those patients with physically aggressive and sexually-inappropriate behavior. Develop audit tool to monitor the care provided to the patient at risk for violence or sexually inappropriate behavior to include the following indicators: a)Plan of care revised to address behavior changes; b) Evidence of progressive action for escalating behavior and c)Corrective actions implemented;
5) Review and revision of policies for Patient's Rights and an Origination of an Organizational policy dated 10/21/11 titled "Management of patients with physically aggressive or sexually inappropriate behavior toward others";
6) Nursing and Non-Nursing (Security Staff) training.

As a result of the hospital's action plan the Immediate Jeopardy was removed on 10/21/11 at 4:50pm. The deficiency remained at Condition Level Noncompliance (see findings in tag A0144).


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Based on record review and interviews, the hospital failed to inform the complainant of the results of the grievance investigation and the steps taken to investigate the grievance for 3 of 4 grievances reviewed (#1, #5, #22). Findings:

Patient #1
Review of Patient #1's grievance revealed she expressed on 07/07/11 her "dissatisfaction with meds (medications) administered" on 07/01/11 in the ED (emergency department). Further review revealed Patient #1 stated the nurse administered Dilaudid immediately after Benadryl and "created a reaction and she felt like she was O/D (overdosed) and is still experiencing severe heart fluttering". Patient #1 "stated gloves were on the nurse, but he pulled off the tips to feel the vein; blood dripped on his finger, he wiped it off, and continue to operate the equipment". Review of response letter addressed to Patient #1 on 07/11/11 and written by ED Director S6 revealed, in part, "...Please accept our apologies for the visit, especially the perceived manner in which your IV (intravenous) procedure was performed. ... We have shared your concerns with the staff and used your feedback as an opportunity to remind them of the importance of communicating to our patients in a manner that alleviates their anxiety...". Further review of the documentation presented by VP (Vice-President) Patient Care Services S2 revealed no documented evidence of an investigation of the grievance and the results of the grievance.

Patient #5
Review of Patient #5's grievance revealed the grievance was made by the spouse of Patient #5. Further review revealed Risk Manager S18 documented on 08/11/11 that "husband ... called alleging that his wife's ankle was fractured when Security personnel brought her back into the hospital from the parking lot. He also stated that her medical records had not been sent to the hospital she was transferred to". Further review revealed ED Director S6 documented on 08/15/11 that she "spoke to patient's husband. Requested speak to patient and he said she had just checked out of hospital today and was resting. I addressed his concerns as best I could due while protecting patient's information; but assured we were investigating his complaints and would notify patient of any necessary or pertinent information that needed to be given to her...". Review of the response letter addressed to Patient #5 and written by ED Director S6 on 08/15/11 revealed, in part, "...I apologize for any frustrations you and your family may have felt regarding the circumstances surrounding the security measures we employ to protect our patients. We consistently review concerns expressed by patients and their family as this helps us to gain more insight and provides an opportunity to review and possibly advance our processes...". Further review of the documentation presented by VP Patient Care Services S2 revealed no documented evidence of an investigation of the grievance and the results of the grievance.

Patient #22
Review of Patient #22's grievance revealed the patient filed a formal verbal complaint on 10/3/11 concerning an incident which involved being struck by a patient on the Acute Behavioral Unit on 10/02/11. Review of the grievance letter sent to patient #22 on 10/11/11 reflected "A complete investigation has been done according to our organizational policy. Your concerns have been shared with out team. We use comments such as yours to improve patient care in the future". There was no documentation to reflect the patient was made aware of the
results of the grievance investigation and the steps taken to investigate the grievance.

Interview with S4, RN-Administrator of Mental Health on 10/20/11 at approximately 11:15am revealed the letter sent to patient #22 was a "generic" letter sent to the patient due to the patient's psychiatric condition. She confirmed the letter did not contain the results of the investigation or the steps taken to investigate the grievance.

In a face-to-face interview on 10/20/11 at 10:15am, Risk Manager S18 indicated she usually doesn't receive complaint/grievance calls directly; they're usually transferred to her if a mention was made during the call regarding an attorney or legal issue. S18 indicated the call from Patient #5's spouse came to her through Guest Services. She further indicated it "was a strange call because when she called him back, she asked to speak to Mr. (name of Patient #5's spouse), he said no and hung up". S18 further indicated she immediately called back and quickly identified herself. S18 indicated Patient #5's spouse said "it's not a complaint, I just want to find out what happened". S18 indicated he said his wife came by ambulance to the ED the previous morning, and she called him from the lobby and said the hospital refused to treat her. S18 indicated she asked Patient #5's spouse why his wife came to the ED, and he said she was having a reaction to pain medications a physician had prescribed. S18 further indicated he told her "we've been in a lot of spats before and I ain't never broke nothing before". S18 further indicated Patient #5's spouse reported that his wife told him she was walking toward the street in front of the hospital, and he thought she was hitching a ride. When asked by the surveyor why this information S18 had reported in interview was not documented as part of the grievance related to her, S18 indicated she usually just writes "something concise". S18 further indicated she didn't remember what she specifically did to investigate this case, but if what's reported was significant, she usually called the department manager or director. S18 further indicated she would not document that she placed the call and referred the matter to the manager or director. After reviewing the "summary of complaint", S18 indicated she could not determine who wrote the report, but thought that someone on the grievance committee may have written it. Risk Manager S18 indicated there was an investigation done, because she called security to request that they review the video from the ED, and she did a chart review. S18 confirmed there was no documented evidence of an investigation performed related to the complaint/grievance.

In a face-to-face interview on 10/20/11 at 11:20am, ED Director S6 indicated she spoke with RN (registered nurse) S10 and RN S16 and reviewed Patient #5's medical record. S6 further indicated she wanted to speak with Patient #5, but Patient #5's spouse told her Patient #5 was unavailable during both phone calls placed to their home. S6 indicated she never heard from Patient #5 after having sent the response letter to her. S6 indicated she had notes of her investigation and the interviews she held related to Patient #5's grievance. S6 presented no documented evidence to the surveyor by the conclusion of the survey of the investigation and the interviews held. S6 confirmed the response letters sent to Patients #1 and #5 did not include results of the grievance investigation and the steps taken to investigate the grievance.

Review of the hospital policy titled "Patient Rights, Complaints, and Grievance Process", reference # OrgClin/020 revised 11/25/10 and submitted by VP Patient Care Services S2 as their current policy for the grievance process, revealed, in part, "...The Grievance Committee or designee will notify the patient filing the grievance in writing of the steps taken to investigate the grievance, the results of the investigation, and the date the investigation was completed...".

Based on record review and interview, the hospital failed to ensure care in a safe setting as evidenced by:
1) Failing to ensure care in a Safe Setting as evidenced by Patient #10 physically striking four patients. 4 of 4 patients (#11, #12, #15, #22) were physically struck by Patient #10 and required medical intervention.
2) Failing to ensure care if safe setting by failing to ensure the RN assessed patients exhibiting behaviors of aggression and sexually inappropriate behaviors and implemented interventions to protect other patients and staff from injury for 3 of 4 patients reviewed who were exhibiting behaviors of aggression and and sexually inappropriate behavior from a total sample of 22 patients (#19, #20, #21). Findings:
1)
Patient #10 Review of the medical record for Patient #10 reflected the patient was admitted to the Acute Behavioral Unit on 09/23/11 at 1800 under a PEC (Physician's Emergency Certificate) for being dangerous to others and gravely disabled. Further review of the PEC revealed the patient had a history of Schizophrenia and Bipolar Disorder. Further review of the PEC revealed that the patient had gotten into an argument with his mother and threatened his mother, so she called the police.
Review of the Coroner's Emergency Certificate (CEC) dated 09/24/11 at 0740 (7:40 a.m.) reflected "...per mother, pt attacked her when she tried to give him his meds, threatened, ran from house...".
Review of Patient #10's admit orders reflected he was placed on "aggression precautions" with routine every 15 minute observations. Review of Patient #10's initial plan of care dated 09/23/11 at 1852 (6:52 p.m.) ,completed by RN (registered nurse) S24 revealed the patient's problems were listed as: ineffective individual coping; alteration in thought process and medication non-adherence. There was no documented evidence that Patient #10 had a plan of care initiated regarding his potential for violent behavior toward others.
Further review of the medical record for Patient #10 revealed the patient was on Routine-Unit precautions, Level 1 (at arm's length) and/or Level II (2) (visual observation line of sight) while hospitalized.
Review of the hospital's "Actual Behavioral Event" dated 09/24/2011 at 8:45am revealed Patient #10 "...was standing in the hall near the nurses' station not stating anything, just staring at various people and things in the hall. Unprovoked, (Patient #10) quickly approached (Patient #11) from the right and struck him on the right lateral aspect of his face - near facial labia and nose. Patient #11 nose and mouth was found to be bleeding and complained of mild discomfort to the area...". Further review revealed Patient #11 required medical intervention and a facial x-ray was completed.
Review of the medical record for Patient #10 revealed he was placed on Level 1 observation after the above incident. Further review revealed the intervention implemented following the above incident was medication management.
Review of the hospital's "Actual Behavioral Event" dated 09/26/2011 at 10:40am revealed Patient #12 "was hit on right forehead by another pt. He got an abrasion and his glasses were damaged. There was no apparent provocation for the incident. Review of the medical record for Patient #12 reflected the patient required medical intervention, and a CT (computerized tomography) scan of the head without contrast was ordered for the patient.
Review of Patient #10's medical record revealed he was the patient who struck Patient #12 on 09/26/11. Patient #10 was on Level 1 observation (one-to-one staff accompaniment at arm's length) during the time of the above incident. Further review revealed the therapeutic measures implemented following the incident was medication administration.
Review of the hospital's "Actual Behavioral Event" report dated 10/02/2011 at 22:15 (10:15pm) revealed "Patient #22 was in the hallway of the acute psych. unit....was approached by Patient #10 ...Patient #10 struck Patient #22 on the left side of her face, leaving redness and minor swelling...". Review of Patient #22's medical record revealed the patient required medical intervention, and a facial x-ray was ordered.
Review of Patient #10's medical record revealed he was on Level 2 observation (continuous visual observation line of sight) during the above incident. Further review revealed the therapeutic intervention implemented following the incident for Patient #10 was medication management. Patient #10 remained on Level 2 after the above incident. There was no documented evidence of any intervention implemented to prevent Patient #10 from assaulting other patients other than medication management.
Review of Patient #10's plan of care reflected the plan was revised on 10/03/2011 to include "Potential for violence/High risk of injury to self or others". Interventions included "Assess and document pt (patient) potential for self-harm and/or violence q (every) shift. Remove all dangerous objects from pt's environment, Encourage pt to seek out staff during periods of increased anxiety, Provide safe therapeutic environment, Other: Line of Sight".
Review of the hospital's "Actual Behavioral Event" report dated 10/09/2011 at 1700 (5:00pm) revealed Patient #15 "was ambulating in the hall when approached by Patient #10. Patient #10 struck Patient #15 on the left side of his forehead using his fist...". Further review of the report revealed Patient #15 was grabbed on the left aspect of his neck with Patient #10's hand. Patient #15 sustained redness and swelling to the left lower forehead and redness to the base of his neck on the left side. Review of Patient #15's physician's orders revealed Patient #15 was ordered a stat(now) CT Scan of the head without contrast.
Review of Patient #10's medical record revealed Patient #12 was placed on Level 1 (1:1 observation) after the above incident.
In a face-to-face interview on 10/18/11 at 3:45pm, RN S24 indicated she completed the admission assessment for Patient #10 and was aware he was at risk for physical aggression. S24 confirmed Patient #10 was ordered physical aggression precautions on admit. S24 further indicated she was on duty for 3 of the 4 physical altercations involving Patient #10. S24 confirmed the initial plan of care did not reflect a care plan for the patient's potential for physical aggression, and the patient's care plan was not revised to reflect a potential for violence/injury until after the incident on 10/02/2011. S24 indicated an intervention to place Patient #10 at a safe distance from other patients was a measure that could have been implemented to safeguard other patients.
In a face-to-face interview on 10/19/11 at 9:50am, Physician S23 indicated he was the attending physician for Patient #10. S23 further indicated he usually set levels of precaution based on the patient's history and behavior in the Emergency Department. S23 indicated he did not think anything else could have been implemented to safeguard the other patients. S23 further indicated he did not want to be overly restrictive or too punitive for Patient #10. S23 confirmed placing the patient at a safe distance from other patients could have been an option for Patient #10.
2)
Patient #19 Review of Patient #19's medical record revealed he was admitted under PEC on 10/16/11 (signed at 1130am) due to being violent, dangerous to self, and gravely disabled. Review of Patient #19's CEC signed on 10/18/11 at 6:45am revealed he was gravely disabled. Review of Patient #19's physician's admit orders revealed special precautions that were ordered included suicide, elopement, and aggression precautions.
Review of Patient #19's History and Physical documented by Physician S33 on 10/17/11 revealed "family also notes sexual inappropriate behavior asking his 17-year-old niece to come over and "get some loving".
Review of Physician S33's progress notes for Patient #19 on 10/18/11 at 11:24am revealed, in part, "...met with pt - sexually preoccupied still...". Review of Physician S33's progress notes for 10/19/11 at 10:17am revealed, in part, "...per staff, pt cont (continues) to be sexually inapprop (inappropriate) - attempting to masturbate while interacting with female nurse. ... Pt notes AH's (auditory hallucinations) + (positive) commands "to have sex with women...".
Review of Patient #19's plan of care revealed the following identified problems and nursing interventions: 1) alteration in thought process initiated on 10/16/11 - interventions included assess patient's level of orientation; frequently orient to surroundings; assess patient for hallucinations/delusions; encourage patient to report delusions/hallucinations to staff before acting on them; provide low stimulus atmosphere; 2) ineffective individual coping initiated 10/16/11 - no documented evidence of interventions and goals; 3) medication non-adherence initiated 10/16/11 - interventions included educate patient on need and importance of medication compliance; encourage patient to express feelings and concerns around taking psych meds; 4) anxiety initiated 10/16/11 - interventions included assess patient's level of anxiety and physical reactions to anxiety every shift; determine how patient copes with anxiety; encourage patient to report episodes of anxiety; reduce sensory stimuli by maintaining a quiet environment; encourage patient to talk about anxious feelings. Further review revealed Patient #19's care plan was reviewed on 10/17/11 and 10/18/11 without revision. Further review revealed no documented evidence that Patient #19 had a care plan initiated and implemented that addressed aggression, suicide, elopement, and sexually-inappropriate behavior.
Patient #20 Review of Patient #20's medical record revealed she was admitted under PEC on 10/14/11 due to positive auditory hallucinations, positive suicidal ideations, being dangerous to self and others, and being gravely disabled. Review of her CEC signed on 10/15/11 at 10:05am revealed Patient #20 remained a danger to herself and others and was gravely disabled.
Review of Patient #20's History and Physical documented by Physician S33 on 10/15/11 revealed, in part, "...She told our emergency room physician ... that she had auditory hallucinations and thoughts of hurting herself or her family. ... Of note, the patient was also threatening to staff in our emergency room. She did acknowledge to me that she was having command hallucinations to kill herself and others in the past several days. ... The COPE assessment documents that patient had thoughts of killing others with a knife or attempting to obtain a gun.
Review of Patient #20's physician's orders revealed orders for aggression and suicide precautions.
Review of Patient #20's plan of care revealed the following identified problems and nursing interventions: 1) ineffective individual coping initiated 10/14/11 - nursing interventions included teach coping skills; instruct on use of relaxation techniques; assess patient's level of anxiety and depression; assist patient in identifying personal strengths and realistic perceptions; encourage patient to verbalize and express feelings and identify stressors; 2) alteration in thought process initiated 10/14/11 - nursing interventions included assess patient's level of orientation; frequently orient to surroundings; assess patient for hallucinations/delusions; encourage patient to report delusions/hallucinations to staff before acting on them; provide low stimulus atmosphere; encourage same staff to work with patient; utilize genuine matter-of-fact approaches; 3) medication non-adherence initiated 10/14/11 - nursing interventions included identify cause of non-adherent behavior; educate patient on need and importance of medication compliance; encourage patient to express feelings and concerns around taking psych meds; mouth checks for expected cheeking; 4) sleep pattern disturbance initiated 10/14/11 - nursing interventions included assist patient to identify possible underlying cause of insomnia; limit daytime napping by providing activities that promote wakefulness; provide environment conducive to sleep; administer therapeutic measures to promote restful sleep. Further review revealed Patient #20's plan of care was reviewed without revision on 10/15/11, 10/16/11, 10/17/11, and 10/18/11. Further review revealed no documented evidence that Patient #20 had a care plan initiated and implemented that addressed aggression and suicide.
Patient #21 Review of Patient #21's medical record revealed he was PEC'd on 10/11/11 at 4:00pm due to being gravely disabled. Further review revealed he was CEC'd on 10/12/11 at 12:20pm due to being gravely disabled.
Review of Patient #21's physician admit orders of 10/11/11 at 4:40pm revealed an order for suicide and aggression precautions.
Review of Patient #21's "Patient Profile" revealed the following entry on 10/11/11 at 19:57 (7:57pm) by RN S 34" "pt d/c'd (discharged) last week from this unit. Non-compliant with meds and threatening staff and pts at ... group home. Cannot return to live there".
Review of "Additional Nursing Notes" revealed an entry by RN S24 on 10/14/11 at 11:30am of "pt became threatening and agitated, attempting to hit female MHT (mental health tech) and threatening to hit female nurse. Unaccepting of verbal redirection from staff, remains intrusive and cursing frequently at staff and peers...". Review of the "Agitated Behavior Scale" completed by RN S24 on 10/14/11 at 7:00am revealed Patient #21 was exhibiting the following behaviors to an extreme degree: sudden changes of mood; restlessness, pacing, excessive movement; uncooperative, resistant to care, demanding; explosive and/or unpredictable anger; violent and/or threatening violence toward people or property.
Review of Patient #21's plan of care revealed the following identified problems and nursing interventions: 1) ineffective individual coping initiated 10/10/11 (patient was admitted on 10/11/11) - nursing interventions included teach coping skills; instruct on use of relaxation techniques; assess patient's level of anxiety and depression; assist patient in identifying personal strengths and realistic perceptions; encourage patient to verbalize and express feelings and identify stressors; 2) alteration in thought process initiated 10/11/11 - nursing interventions included assess patient's level of orientation; frequently orient to surroundings; assess patient for hallucinations/delusions; encourage patient to report delusions/hallucinations to staff before acting on them; provide low stimulus atmosphere; 3) medication non-adherence initiated 10/11/11 - nursing interventions included identify cause of non-adherent behavior; educate patient on need and importance of medication compliance; mouth checks for expected cheeking; 4) risk for injury (high risk for injury to self) initiated 10/11/11 - nursing interventions included assess and document pt potential for self-harm and/or violence every shift; remove all dangerous objects from pt's environment; implement suicide precautions. Further review revealed Patient #21's care plan had been reviewed without revision on 10/14/11, 10/15/11, 10/16/11, 10/17/11, and 10/18/11. Further review revealed no documented evidence that Patient #21 had a care plan initiated and implemented that addressed aggression and risk for injury to others.
In a face-to-face interview on 10/19/11 at 11:10am, Administrator of Mental Health S4 indicated the hospital's computer system did not have aggression and sexually-inappropriate behavior as choices from which to select for patient problems when initiating the care plan. S4 further indicated the nurses would have to relay the information from shift-to-shift.
In a face-to-face interview on 10/19/11 at 11:50am, Administrator of Mental Health S4 indicated management had identified the problem with the computer system regarding care plans for aggression and sexually-inappropriate behavior. S4 further indicated the problem had been addressed through the IT department, but it had not been addressed through nursing services.
Review of the hospital's policy titled "Special Precautions", number BPN-018 revised May 2011 and submitted as the hospital's current policy for special precautions and observation levels, revealed, in part, "...Special precaution procedures can be initiated by physician or nursing staff when a patient is considered to be an increased risk for harm to self, others or property... Restriction of any patient rights due to special precautions should be addressed in the patient's treatment plan. ... The need for special observation is reflected in the patient's treatment plan or plan of care...". Review of the policy revealed Routine/Unit precautions included a minimum of every 15 minute observations for 24 hours after admission and then every 30 minutes. Review of Level 1 observations revealed 1:1 (one-to-one) staff accompaniment (at arm's length) was required at all times. Review of Level II (2) observations revealed continuous visual observation (Line of Sight) was required. With this level, the patient was required to be within visual range of the assigned staff at all times.
Review of the hospital policy titled "Patient Assessment/Reassessment", number ORGClin/031 revised 08/30/10 and submitted as the current policy for initiation of the plan of care, revealed, in part, "...Inpatient Assessment and Reassessment Timeframes ... Mental/Behavioral Health ... Plan of Care 24 hrs (hours) ... Reassessment .... reassess every 12 hours...".


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Based on record review and interview, the hospital failed to: 1) include in their Quality Assessment Performance Improvement (QAPI) activities high-risk, high-volume, and/or problem-prone areas of patient care related to the Emergency Department (ED) as evidenced by failure to include and track ED patients under Physician Emergency Certificate (PEC) in the QAPI quality monitors and 2) ensure quality indicators were reviewed timely for problem-prone areas identified in Quality Improvement for the acute behavioral unit. Findings:

1) Failure to include and track ED patients under Physician Emergency Certificate (PEC) in the QAPI quality monitors:

Review of the "Adult ECU (emergency care unit) Performance Excellence Dashboard" from January 2011 to present, presented by Director of Quality Management S31 as the current quality indicators for the ED, revealed no documented evidence that the medical records of ED patients under PEC were reviewed to determine that ED policy was followed regarding the one-to-one observation of patients in the ED under PEC.

Patient #5 Review of Patient #5's medical record revealed she presented to the ED on 08/10/11 at 8:01am with the presenting problem of suicidal ideation. Review of the "ED Triage Assessment" entered on 08/10/11 at 8:32am by RN S10 revealed, in part, "...pt (patient) just abandoned Er (emergency room) after "not getting treated" for left shoulder pain. pt heard by staff stating she would "walk into traffic". pt taken to Room "c", not cooperative. denies SI (suicidal ideation) at this time...". Further review of Patient #5's ED record revealed she was transferred to an inpatient behavioral hospital on 08/10/11 at 2:28pm.
Review of Patient #5's "Physician Emergency Certificate" (PEC) revealed it was signed on 08/10/11 at 8:15am due to Patient #5 being suicidal and dangerous to self. Review of Patient #5's entire ED record revealed no documented evidence of one-to-one visual observation of Patient #5 by a mental health tech (MHT), security representative, or other staff member as required by ED policy for all patients who were under PEC.
Patient #7 Review of Patient #7's ED record revealed she presented to the ED on 09/14/11 at 11:14am with the presenting problem documented as emotional disturbance. Review of Patient #7's PEC revealed it was signed on 09/14/11 at 2:00pm due to Patient #7 being gravely disabled. Further review of the PEC revealed, in part, "...53 yo (year old) (sign for female) brought in by her daughter 2 (secondary to) (arrows pointing upward - increasing) dementia & (and) wandering unable to care for patient @ (at) home, pt (patient) went missing yest (yesterday) for (approximately) 6 (hours)...". Further review of Patient #7's ED record revealed she was transferred to an inpatient behavioral hospital on 09/14/11 at 7:20pm.
Review of Patient #7's "Patient Observation Record" dated 09/14/11 revealed the level of observation was "continuous visual (line of sight)". Further review revealed the blanks from 12:30pm, 12:45pm, and 1:00pm had the word "lunch" written across the blanks by MHT S35. There was no documented evidence of continuous visual observation of Patient 7 from 12:30pm to 1:30pm on 09/14/11 as required by ED policy for patients who were under PEC.
Patient #8 Review of Patient #8's ED record revealed he presented to the ED on 09/11/11 at 12:04pm with the presenting problem of emotional disturbance. Further review revealed he was PEC'd on 09/11/11 at 2:20pm due to being suicidal, dangerous to self, and gravely disabled. Further review revealed to transferred from the ED to the inpatient behavioral unit on 09/11/11 at 6:20pm. Review of the entire ED record revealed no documented evidence Patient #8 was continuously observed one-to-one while in the ED after being PEC'd as required by ED policy for all patients who were under PEC.
In a face-to-face interview on 10/19/11 at 3:40pm, Director of Security S3 indicated security representatives were assigned to the ED and were responsible for the entire ED. He further indicated that on occasion the security representative was assigned to perform one-to-one observation of a patient in an ED room. S3 indicated the security representative used a PEC custody form to document their observations. S3 further indicated the security representatives were not knowledgeable of the "Patient Observation Record" used by the MHTs to document their one-to-one observations.
Review of the monitoring log presented by Director of Security S3 as the PEC custody form used by security representatives when monitoring patients in the ED who were under PEC revealed the following: Section A - date, time, patient name, age, gender, race; Section B - "This section is to be completed during every hand-off between staff"; column for time, report given by, report received by, green wristband in place, check all risk issues that apply (danger to self, danger to others, flight, other). Further review revealed no documented evidence that security representative was required to document other than the time they start observing and the time they hand-off to another representative.
In a face-to-face interview on 10/19/11 at 4:00pm, ED Director S6 indicated one-to-one constant observation meant the employee was to have their eyes on the patient at all times. S6 indicated the ED had no policy that defined what one-to-one observation required. S6 indicated the PEC custody form used by the security staff when they observe patients in the ED did not become a permanent part of the ED patient's medical record. S6 confirmed there was no documented evidence of continuous one-to-one observation of Patient #7 during the lunch period.
In a face-to-face interview on 10/20/11 at 8:45am, Director of Security S3 indicated he could not provide a PEC custody form for Patients #7 and #8, because security was not called to provide the observation for these two patients.
Patient R1 Review of Patient R1's PEC revealed he was PEC'd on 10/20/11 at 11:00am due to being suicidal and dangerous to self.
Observation on 10/20/11 at 12:10pm revealed Patient R1 was admitted to room "a" in the ED which had an otoscope, ophthalmoscope, blood pressure cuff, and an electric bed with cords hanging. Continuous observation further revealed RN S19 walked away from his position at the nursing station (which allowed him to visually observe Patient R1), and Security Representative S20 was standing in the hallway across from room "a" with his back to Patient R1. This observation was made in the presence of ED Director S6.
Patient R2 Review of Patient R2's ED record revealed he was PEC'd on 10/19/11 at 2252 (10:52pm) due to being suicidal, dangerous to self, and gravely disabled.
Observation on 10/20/11 at 12:20pm revealed Patient R2 was admitted to room "b" in the ED which had an otoscope, ophthalmoscope, blood pressure cuff, and an electric bed with cords hanging. Continuous observation further revealed Security Representative S21, responsible for one-to-one observation of Patient R2, stood in the hallway speaking with another individual while she (S21) had her back to Patient R2. This observation was made in the presence of and confirmed by ED Director S6.
In a face-to-face interview on 10/20/11 at 12:05pm, Security Representative S21 indicated she and Security Representative S20 were responsible for observing Patients R1 and R2, which meant that they (S20 and S21) were to keep their eyes on Patients R1 and R2 at all times.
Patient R3 Review of Patient R3's ED record revealed he was PEC'd on 10/20/11 at 10:06am due to being dangerous to self and gravely disabled.
Observation on 10/20/11 at 12:25pm revealed room "c" in the ED had three patients being observed by MHT S23. Further continuous observation revealed Patient R3 was seated in a recliner positioned to the right of the door entrance to room "c". Further observation revealed the recliner was positioned against the wall that was half wall and half glass window, making the patient seated in the recliner not visible to the staff member seated in the hall outside room "c". Continuous observation further revealed MHT S23 walking in the hallway with his back to the door of room "c" and thus not having continuous visual observation of Patient R3. This observation was made in the presence of ED Director S6.
Patient R4 Review of Patient R4's ED record revealed he was PEC'd on 10/19/11 at 11:45pm due to being suicidal, dangerous to self, dangerous to others, and gravely disabled.
Observation on 10/20/11 at 12:25pm revealed room "c" in the ED had three patients being observed by MHT S23. Further continuous observation revealed Patient R4 was seated in a recliner located in the right rear corner of room "c" totally covered by a blanket. Continuous observation further revealed MHT S23, who was assigned to observe Patient R4 one-to-one, walking in the hallway with his back to the door of room "c" and thus not having continuous visual observation of Patient R4. This observation was made in the presence of ED Director S6.
In a face-to-face interview on 10/20/11 at 12:25pm, MHT S23 indicated he was responsible for observing Patients R3 and R4.
Review of the hospital's ED policy titled "Physicians Emergency Certificate (PEC)", number MH-02 last revised 03/28/05, last reviewed 03/11, and presented as the current policy for monitoring PEC'd patients in the ED, revealed, in part, "...Purpose: To establish guidelines for a patient who is placed under the Physicians Emergency Certificate. ... Patients that are under PEC, OPC (order of protective custody), CEC (Coroner's Emergency Certificate), and Peace Officers hold are to have 1:1 (one-to-one) observation by Mental Health Tech, Security, or other staff member".

In a face-to-face interview on 10/20/11 at 2:03pm, Director of Quality Management S31 indicated development of quality indicators for performance improvement focused on high-risk, high-volume, and/or problem-prone areas. S31 confirmed the ED patients under PEC would be considered a high-risk, problem-prone area for the ED. S31 indicated events in patient safety were reviewed in the patient safety work group. He further indicated, as Director of Quality Management, he would be aware if there had been tracking and trending with resultant corrective action for PEC'd patients in the ED. S31 confirmed patients under PEC in the ED was not an area selected for quality improvement, and the identified problem related to the lack of one-to-one monitoring of PEC'd patients had not been identified by the hospital.

Review of the hospital's "Patient Safety and Quality PI (performance improvement) Plan", submitted by Director of Quality Management S31 as their current QAPI (quality assessment and performance improvement) plan, revealed, in part, "...To ensure strategic alignment, quality improvement activities emerge from a systematic and organized framework for improvement... This quality improvement framework incorporates four primary activities. Building a culture of patient safety, quality and reliability; Value-added measurement and the assessment of hospital performance through the collection and analysis of data. Identifying opportunities for excellence through active participation (rounding) and team member feedback; Conducting quality improvement and patient safety initiatives and taking action where indicated, including the: design of new services, and/or improvement of existing services. ... Selection of a Performance Indicator. A performance indicator is a quantitative tool that provides information about the performance of the hospital's process, services, functions or outcomes. Selection of a Performance Indicator is based on the following considerations: Relevance to mission ... Relevance to Five Pillars and Strategic Plan ... Organizational importance - whether it addresses important processes that are: high volume, problem prone or high risk...".

2) Ensure quality indicators were reviewed timely for problem-prone areas identified in Quality Improvement for the acute behavioral unit:
Review of the Quality Indicators for the Acute Behavioral Unit revealed "Environment of Care Indicator-Patient Safety included Adult Patient Self Injury and Adult Patient Assault and Elopements were areas that were being tracked and trended.

In an interview on 10/20/2011 at 2:05pm, Director of Quality Management S31 indicated data for the Mental Behavioral Unit was obtained from incident reports. He revealed the data that was obtained for the quarter ending on June 30, 2011 was evaluated and discussed in their Patient Safety Workgroup Meeting on October 7, 2011. S31 stated the Environment Patient Safety meetings are held monthly, however the information discussed in the Performance Improvement Meetings are information that's 3 months old. S31 further confirmed that recent data obtained would not be discussed until 3 months later.

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

1) Failing to ensure the registered nurse (RN) supervised the care of Emergency Department (ED) patients as evidenced by failure to implement the system for one-to-one observation of ED patients who were under Physician's Emergency Certificate (PEC) as required by ED policy for 3 of 3 ED patients reviewed who were under PEC (#5, #7, #8) from a total sample of 22 patients and for 4 of 4 random ED patients under PEC observed on 10/20/11 (R1, R2, R3, R4).

Vice-President Patient Care Services S2 was notified on 10/20/11 at 3:00pm of an immediate jeopardy situation when the RN (Registered Nurse) failed to implement the system for one-to-one observation of ED patients who were under Physician's Emergency Certificate (PEC) as required by ED policy. The policy failed to define the elements of one-to-one observation to include if the patient was to be on continuous observation, whether the observation required the observer to have eye contact on the patient, the time frame for documentation requirements, the location of the patient when being observed, and the manner of incorporating security representative monitoring in the patient's medical record.

Patient #5 was PEC'd on 08/10/11 at 8:15am as suicidal and dangerous to self. Patient #7 was PEC'd on 09/04/11 at 2:00pm as gravely disabled. Patient #8 was PEC'd on 09/11/11 at 2:20pm as suicidal, dangerous to self, and gravely disabled. The hospital could provide no observation records for Patients #5 and #8, and the observation record for Patient #7 revealed no observation from 12:30pm to 1:15pm on 09/14/11.

In interview on 10/20/11 at 8:45am, Director of Security S3 presented the security monitoring log for Patient #5. The log revealed the name of the security representative and the time they received report on Patient #5, the name of the person giving the report, and the risk that applied to Patient #5. S3 confirmed there was no observation record completed by the security representative for Patient #5. S3 further confirmed he had no documented evidence of a security monitoring log for Patients #7 and #8, because security was not requested to observe Patients #7 and #8.

Observations of the ED on 10/20/11 revealed the following:
a) 12:10pm Random Patient R1, PEC'd on 10/20/11 at 11:00am as suicidal and dangerous to self, was admitted to room "a" in the ED which had an otoscope, ophthalmoscope, blood pressure cuff, and an electric bed with cords hanging. Continuous observation further revealed RN S19 walked away from his position at the nursing station (which allowed him to visually observe Patient R1), and Security Representative S20 was standing in the hallway across from room "a" with his back to Patient R1. This observation was made in the presence of ED Director S6. b) 12:20pm Random Patient R2, PEC'd on 10/19/11 at 2252 (10:52pm) as suicidal and dangerous to self, was admitted to room "b" in the ED which had an otoscope, ophthalmoscope, blood pressure cuff, and an electric bed with cords hanging. Continuous observation further revealed Security Representative S21, responsible for one-to-one observation of Patient R2, stood in the hallway speaking with another individual while she (S21) had her back to Patient R2. This observation was made in the presence of and confirmed by ED Director S6. c) 12:25pm Observation of room "c" revealed Random Patient R3, who had been PEC'd on 10/20/11 at 10:06am as dangerous to self, was seated in a recliner positioned to the right of the door entrance. Further observation revealed Random Patient R4, who was PEC'd on 10/19/11 at 11:45pm as suicidal, dangerous to self, and dangerous to others, was seated in the recliner located in the right rear corner of the room covered by a blanket. Further observation revealed MHT (mental health tech) S23 walking in the hallway with his back to the door of room "c", and thus not having visual observation of Random Patients R3 and R4. This observation was confirmed by ED Director S6.
In a face-to-face interview on 10/20/11 at 12:05pm, Security Representative S21 indicated she and Security Representative S20 were responsible for observing Patients R1 and R2, which meant that they (S20 and S21) were to keep their eyes on Patients R1 and R2 at all times.
In a face-to-face interview on 10/20/11 at 12:25pm, MHT S23 indicated he was responsible for observing Patients R3 and R4.
A plan of removal developed by Vice-President Patient Care Services S2 was presented to the survey team on 10/21/11 at 4:50pm. Review of the plan of removal revealed the following:
a) Ensure that a staff member (MHT, RN, Security personnel) is assigned to each of the current PEC patients in the ED;
b) Educate each staff member currently assigned to the PEC patient on the observation of these patients and the suicidal patient. Re-educate RN on responsibility of supervising;
c) Document staff education with sign-in sheets;
d) Ensure that no staff member who has not received training prior to his/her shift is assigned to care for any PEC patients;
e) Ensure that each observer is documenting on the appropriate form and the form is placed in the patient's record;
f) Develop audit tool and audit results of immediate teaching;
g) Research best practices and indicate references in policy;
h) Revise policy to reflect the elements of observation, RN accountability, clarify 1:1 observation, and specify RN delegation assignment to non-licensed staff;
i) Educate staff on the newly revised PEC policy. No staff member assigned to PEC patient prior to education;
j) Re-educate all ED staff on patient rights;
k) Audit daily observation records of PEC patients for patient chart daily times 30 days until 100% (per cent). If not 100% continue an additional 30 days. Then if 100%, then weekly times three months. Then if 100%, monthly times 6 months;
l) Audit daily observation of PEC patients on process for patient chart daily x (times) 30 days until 100%. If not 100% continue an additional 30 days. Then if 100%, then weekly x 3 months. Then if 100%, monthly x 6 months.
m) Develop skills competency checklist to demonstrate competency of non-licensed personnel to perform 1:1 observation and constant monitoring.

As a result of the hospital's action plan the Immediate Jeopardy was removed on 10/21/11 at 4:50pm.
The deficiency remains at a Condition Level. (see findings at tag A0395).

2) Failing to ensure the RN assessed patients with diagnoses of and/or exhibiting behaviors of aggression and/or sexually inappropriate behaviors and implemented interventions to protect other patients and staff from injury for 3 of 4 inpatients reviewed with diagnoses of and/or documented behaviors of aggression and/or sexually-inappropriate behavior from a total sample of 22 patients (#19, #20, #21) (see findings in tag A0395).

Based on observations, record review, and interviews, the hospital failed to ensure: 1) the registered nurse (RN) supervised the care of Emergency Department (ED) patients as evidenced by failing to implement the system for one-to-one observation of ED patients who were under Physician's Emergency Certificate (PEC) as required by ED policy for 3 of 3 ED patients reviewed who were under PEC (#5, #7, #8) from a total sample of 22 patients and for 4 of 4 random ED patients under PEC observed on 10/20/11 (R1, R2, R3, R4) and 2) the RN assessed patients with diagnoses of and/or exhibiting behaviors of aggression and/or sexually inappropriate behaviors and implemented interventions to protect other patients and staff from injury for 3 of 4 inpatients reviewed with diagnoses of and/or documented behaviors of aggression and/or sexually-inappropriate behavior from a total sample of 22 patients (#19, #20, #21). Findings:
1) RN supervised the care of the ED patients as evidenced by failing to implement the system for one-to-one observation of ED patients who were under PEC as required by ED policy: Patient #5 Review of Patient #5's medical record revealed she presented to the ED on 08/10/11 at 8:01am with the presenting problem of suicidal ideation. Review of the "ED Triage Assessment" entered on 08/10/11 at 8:32am by RN S10 revealed, in part, "...pt (patient) just abandoned Er (emergency room) after "not getting treated" for left shoulder pain. pt heard by staff stating she would "walk into traffic". pt taken to Room "c", not cooperative. denies SI (suicidal ideation) at this time...". Further review of Patient #5's ED record revealed she was transferred to an inpatient behavioral hospital on 08/10/11 at 2:28pm.
Review of Patient #5's "Physician Emergency Certificate" (PEC) revealed it was signed on 08/10/11 at 8:15am due to Patient #5 being suicidal and dangerous to self. Review of Patient #5's entire ED record revealed no documented evidence of one-to-one visual observation of Patient #5 by a mental health tech (MHT), security representative, or other staff member as required by ED policy for all patients who were under PEC.
Patient #7 Review of Patient #7's ED record revealed she presented to the ED on 09/14/11 at 11:14am with the presenting problem documented as emotional disturbance. Review of Patient #7's PEC revealed it was signed on 09/14/11 at 2:00pm due to Patient #7 being gravely disabled. Further review of the PEC revealed, in part, "...53 yo (year old) (sign for female) brought in by her daughter 2 (secondary to) (arrows pointing upward - increasing) dementia & (and) wandering unable to care for patient @ (at) home, pt (patient) went missing yest (yesterday) for (approximately) 6 (hours)...". Further review of Patient #7's ED record revealed she was transferred to an inpatient behavioral hospital on 09/14/11 at 7:20pm.
Review of Patient #7's "Patient Observation Record" dated 09/14/11 revealed the level of observation was "continuous visual (line of sight)". Further review revealed the blanks from 12:30pm, 12:45pm, and 1:00pm had the word "lunch" written across the blanks by MHT S35. There was no documented evidence of continuous visual observation of Patient 7 from 12:30pm to 1:30pm on 09/14/11 as required by ED policy for patients who were under PEC.
Patient #8 Review of Patient #8's ED record revealed he presented to the ED on 09/11/11 at 12:04pm with the presenting problem of emotional disturbance. Further review revealed he was PEC'd on 09/11/11 at 2:20pm due to being suicidal, dangerous to self, and gravely disabled. Further review revealed to transferred from the ED to the inpatient behavioral unit on 09/11/11 at 6:20pm. Review of the entire ED record revealed no documented evidence Patient #8 was continuously observed one-to-one while in the ED after being PEC'd as required by ED policy for all patients who were under PEC.
In a face-to-face interview on 10/19/11 at 3:40pm, Director of Security S3 indicated security representatives were assigned to the ED and were responsible for the entire ED. He further indicated that on occasion the security representative was assigned to perform one-to-one observation of a patient in an ED room. S3 indicated the security representative used a PEC custody form to document their observations. S3 further indicated the security representatives were not knowledgeable of the "Patient Observation Record" used by the MHTs to document their one-to-one observations.
Review of the monitoring log presented by Director of Security S3 as the PEC custody form used by security representatives when monitoring patients in the ED who were under PEC revealed the following: Section A - date, time, patient name, age, gender, race; Section B - "This section is to be completed during every hand-off between staff"; column for time, report given by, report received by, green wristband in place, check all risk issues that apply (danger to self, danger to others, flight, other). Further review revealed no documented evidence that security representative was required to document other than the time they start observing and the time they hand-off to another representative.
In a face-to-face interview on 10/19/11 at 4:00pm, ED Director S6 indicated one-to-one constant observation meant the employee was to have their eyes on the patient at all times. S6 indicated the ED had no policy that defined what one-to-one observation required. S6 indicated the PEC custody form used by the security staff when they observe patients in the ED did not become a permanent part of the ED patient's medical record. S6 confirmed there was no documented evidence of continuous one-to-one observation of Patient #7 during the lunch period.
In a face-to-face interview on 10/20/11 at 8:45am, Director of Security S3 indicated he could not provide a PEC custody form for Patients #7 and #8, because security was not called to provide the observation for these two patients.
Patient R1 Review of Patient R1's PEC revealed he was PEC'd on 10/20/11 at 11:00am due to being suicidal and dangerous to self.
Observation on 10/20/11 at 12:10pm revealed Patient R1 was admitted to room "a" in the ED which had an otoscope, ophthalmoscope, blood pressure cuff, and an electric bed with cords hanging. Continuous observation further revealed RN S19 walked away from his position at the nursing station (which allowed him to visually observe Patient R1), and Security Representative S20 was standing in the hallway across from room "a" with his back to Patient R1. This observation was made in the presence of ED Director S6.
Patient R2 Review of Patient R2's ED record revealed he was PEC'd on 10/19/11 at 2252 (10:52pm) due to being suicidal, dangerous to self, and gravely disabled.
Observation on 10/20/11 at 12:20pm revealed Patient R2 was admitted to room "b" in the ED which had an otoscope, ophthalmoscope, blood pressure cuff, and an electric bed with cords hanging. Continuous observation further revealed Security Representative S21, responsible for one-to-one observation of Patient R2, stood in the hallway speaking with another individual while she (S21) had her back to Patient R2. This observation was made in the presence of and confirmed by ED Director S6.
In a face-to-face interview on 10/20/11 at 12:05pm, Security Representative S21 indicated she and Security Representative S20 were responsible for observing Patients R1 and R2, which meant that they (S20 and S21) were to keep their eyes on Patients R1 and R2 at all times.
Patient R3 Review of Patient R3's ED record revealed he was PEC'd on 10/20/11 at 10:06am due to being dangerous to self and gravely disabled.
Observation on 10/20/11 at 12:25pm revealed room "c" in the ED had three patients being observed by MHT S23. Further continuous observation revealed Patient R3 was seated in a recliner positioned to the right of the door entrance to room "c". Further observation revealed the recliner was positioned against the wall that was half wall and half glass window, making the patient seated in the recliner not visible to the staff member seated in the hall outside room "c". Continuous observation further revealed MHT S23 walking in the hallway with his back to the door of room "c" and thus not having continuous visual observation of Patient R3. This observation was made in the presence of ED Director S6.
Patient R4 Review of Patient R4's ED record revealed he was PEC'd on 10/19/11 at 11:45pm due to being suicidal, dangerous to self, dangerous to others, and gravely disabled.
Observation on 10/20/11 at 12:25pm revealed room "c" in the ED had three patients being observed by MHT S23. Further continuous observation revealed Patient R4 was seated in a recliner located in the right rear corner of room "c" totally covered by a blanket. Continuous observation further revealed MHT S23, who was assigned to observe Patient R4 one-to-one, walking in the hallway with his back to the door of room "c" and thus not having continuous visual observation of Patient R4. This observation was made in the presence of ED Director S6.
In a face-to-face interview on 10/20/11 at 12:25pm, MHT S23 indicated he was responsible for observing Patients R3 and R4.
Review of the hospital's ED policy titled "Physicians Emergency Certificate (PEC)", number MH-02 last revised 03/28/05, last reviewed 03/11, and presented as the current policy for monitoring PEC'd patients in the ED, revealed, in part, "...Purpose: To establish guidelines for a patient who is placed under the Physicians Emergency Certificate. ... Patients that are under PEC, OPC (order of protective custody), CEC (Coroner's Emergency Certificate), and Peace Officers hold are to have 1:1 (one-to-one) observation by Mental Health Tech, Security, or other staff member". The policy failed to define the elements of one-to-one observation to include if the patient was to be on continuous observation, whether the observation required the observer to have eye contact on the patient, the time frame for documentation requirements, the location of the patient when being observed, and the manner of incorporating security representative monitoring in the patient's medical record.

2) RN assessed patients with diagnoses of and/or exhibiting behaviors of aggression and/or sexually inappropriate behaviors and implemented interventions to protect other patients and staff from injury: Patient #19 Review of Patient #19's medical record revealed he was admitted under PEC on 10/16/11 (signed at 1130am) due to being violent, dangerous to self, and gravely disabled. Review of Patient #19's CEC signed on 10/18/11 at 6:45am revealed he was gravely disabled. Review of Patient #19's physician's admit orders revealed special precautions that were ordered included suicide, elopement, and aggression precautions.
Review of Patient #19's History and Physical documented by Physician S33 on 10/17/11 revealed "family also notes sexual inappropriate behavior asking his 17-year-old niece to come over and "get some loving".
Review of Physician S33's progress notes for Patient #19 on 10/18/11 at 11:24am revealed, in part, "...met with pt - sexually preoccupied still...". Review of Physician S33's progress notes for 10/19/11 at 10:17am revealed, in part, "...per staff, pt cont (continues) to be sexually inapprop (inappropriate) - attempting to masturbate while interacting with female nurse. ... Pt notes AH's (auditory hallucinations) + (positive) commands "to have sex with women...".
Review of Patient #19's plan of care revealed no documented evidence that Patient #19 had a care plan initiated and implemented that addressed aggression, suicide, elopement, and sexually-inappropriate behavior. There was no nursing intervention implemented to ensure the safety of other patients from Patient #19's sexually-inappropriate behaviors.
Patient #20 Review of Patient #20's medical record revealed she was admitted under PEC on 10/14/11 due to positive auditory hallucinations, positive suicidal ideations, being dangerous to self and others, and being gravely disabled. Review of her CEC signed on 10/15/11 at 10:05am revealed Patient #20 remained a danger to herself and others and was gravely disabled.
Review of Patient #20's History and Physical documented by Physician S33 on 10/15/11 revealed, in part, "...She told our emergency room physician ... that she had auditory hallucinations and thoughts of hurting herself or her family. ... Of note, the patient was also threatening to staff in our emergency room. She did acknowledge to me that she was having command hallucinations to kill herself and others in the past several days. ... The COPE assessment documents that patient had thoughts of killing others with a knife or attempting to obtain a gun.
Review of Patient #20's physician's orders revealed orders for aggression and suicide precautions.
Review of Patient #20's plan of care revealed no documented evidence that Patient #20 had a care plan initiated and implemented that addressed aggression and suicide. There was no documented evidence of nursing interventions implemented to ensure the safety of Patient #20, as well as the other patients on the unit from the potential aggressive behaviors of Patient #20.
Patient #21 Review of Patient #21's medical record revealed he was PEC'd on 10/11/11 at 4:00pm due to being gravely disabled. Further review revealed he was CEC'd on 10/12/11 at 12:20pm due to being gravely disabled.
Review of Patient #21's physician admit orders of 10/11/11 at 4:40pm revealed an order for suicide and aggression precautions.
Review of Patient #21's "Patient Profile" revealed the following entry on 10/11/11 at 19:57 (7:57pm) by RN S 34" "pt d/c'd (discharged) last week from this unit. Non-compliant with meds and threatening staff and pts at ... group home. Cannot return to live there".
Review of "Additional Nursing Notes" revealed an entry by RN S24 on 10/14/11 at 11:30am of "pt became threatening and agitated, attempting to hit female MHT (mental health tech) and threatening to hit female nurse. Unaccepting of verbal redirection from staff, remains intrusive and cursing frequently at staff and peers...". Review of the "Agitated Behavior Scale" completed by RN S24 on 10/14/11 at 7:00am revealed Patient #21 was exhibiting the following behaviors to an extreme degree: sudden changes of mood; restlessness, pacing, excessive movement; uncooperative, resistant to care, demanding; explosive and/or unpredictable anger; violent and/or threatening violence toward people or property.
Review of Patient #21's plan of care revealed the care plan for risk for injury (high risk for injury to self) was initiated 10/11/11, and the nursing interventions included assess and document pt potential for self-harm and/or violence every shift; remove all dangerous objects from pt's environment; implement suicide precautions. Further review revealed no documented evidence that Patient #21 had nursing interventions implemented that addressed aggression and risk for injury to others.
In a face-to-face interview on 10/19/11 at 11:10am, Administrator of Mental Health S4 indicated the hospital's computer system did not have aggression and sexually-inappropriate behavior as choices from which to select for patient problems when initiating the care plan. S4 further indicated the nurses would have to relay the information from shift-to-shift. S4 confirmed there was no documented evidence of nursing interventions that addressed the aggression and/or sexually inappropriate behaviors of Patients #19, #20, and #21.
Review of the hospital's policy titled "Special Precautions", number BPN-018 revised May 2011 and submitted as the hospital's current policy for special precautions and observation levels, revealed, in part, "...Special precaution procedures can be initiated by physician or nursing staff when a patient is considered to be an increased risk for harm to self, others or property... Restriction of any patient rights due to special precautions should be addressed in the patient's treatment plan...".
Review of the hospital policy titled "Patient Assessment/Reassessment", number ORGClin/031 revised 08/30/10 and submitted as the current policy for initiation of the plan of care, revealed, in part, "...Inpatient Assessment and Reassessment Timeframes ... Mental/Behavioral Health ... Plan of Care 24 hrs (hours) ... Reassessment .... reassess every 12 hours...".

Based on record review and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan as evidenced by failing to ensure nursing interventions and goals were identified and implemented to address physically aggressive and/or sexually-inappropriate behavior for 4 of 4 inpatients reviewed with diagnoses of and/or documented behaviors of aggression and/or sexually-inappropriate behavior from a total sample of 22 patients (#10, #19, #20, #21). Findings:

Patient #10
Review of the medical record for Patient #10 revealed the patient was admitted to the Acute Behavioral Unit on 09/23/11 at 1800 (6:00pm) under a PEC (Physician's Emergency Certificate) for being dangerous to others and gravely disabled. Further review of the PEC revealed Patient #10 had a history of Schizophrenia and Bipolar Disorder. Further review revealed Patient #10 had gotten into an argument with his mother and threatened her, so she called the police.
Review of the Coroner's Emergency Certificate (CEC) dated 09/24/11 at 0740 (7:40am) revealed "...per mother, pt (patient) attacked her when she tried to give him his meds, threatened, ran from house...".
Review of Patient #10's admit orders revealed he was placed on "aggression precautions" with routine every 15 minute observations. Review of Patient #10's initial plan of care dated 09/23/11 at 1852 (6:52pm) ,completed by RN (registered nurse) S24, revealed the patient's problems were listed as: ineffective individual coping; alteration in thought process and medication non-adherence. There was no documented evidence that a plan of care was initiated for Patient #10 regarding his potential for violent behavior toward others.
In a face-to-face interview with RN S24 on 10/18/2011 at 3:45pm indicated she completed the admission assessment for Patient #10 and was aware he was at risk for physical aggression. S24 confirmed Patient #10 was ordered physical aggression precautions on admit. RN S24 further indicated she was on duty for 3 of the 4 physical altercations involving Patient #10. S24 confirmed the initial plan of care did not reflect a care plan for the patient's potential for physical aggression, and the patient's care plan was not revised to reflect a potential for violence/injury until after the incident on 10/02/2011.
In a face-to-face interview on 10/19/11 at 1:25pm, RN S29 indicated she was on duty when Patient #10 struck Patient #12 on 09/26/11. S29 indicated this altercation occurred when the patients were in group therapy, and Patient #10 struck Patient #12 without provocation. S29 further indicated there were no changes made to Patient #10's plan of care, and the intervention implemented was to give Patient #10 medication. Patient #10 was then escorted to his room to de-escalate.
Review of Patient #10's record reflected he struck Patient #22 on 10/02/11. Review of Patient #10's care plan revealed it was not revised until after Patient #10 had struck the 3rd patient (Patient #22) on 10/02/11. Review of Patient #10's revised plan of care revealed a plan for "Potential for violence/High risk of injury to self or others" was added on 10/03/11. Interventions included "assess and document pt potential for self-harm and/or violence q (every) shift. Remove all dangerous objects from pt's environment, Encourage pt to seek out staff during periods of increased anxiety, Provide safe therapeutic environment, Other: Line of Sight". There was no documented evidence on the revised plan of care to reflect what other measures would be implemented to ensure the safety of other patients on the unit.
Patient #19 Review of Patient #19's medical record revealed he was admitted under PEC on 10/16/11 (signed at 1130am) due to being violent, dangerous to self, and gravely disabled. Review of Patient #19's CEC signed on 10/18/11 at 6:45am revealed he was gravely disabled. Review of Patient #19's physician's admit orders revealed special precautions that were ordered included suicide, elopement, and aggression precautions.
Review of Patient #19's History and Physical documented by Physician S33 on 10/17/11 revealed "family also notes sexual inappropriate behavior asking his 17-year-old niece to come over and "get some loving".
Review of Physician S33's progress notes for Patient #19 on 10/18/11 at 11:24am revealed, in part, "...met with pt - sexually preoccupied still...". Review of Physician S33's progress notes for 10/19/11 at 10:17am revealed, in part, "...per staff, pt cont (continues) to be sexually inapprop (inappropriate) - attempting to masturbate while interacting with female nurse. ... Pt notes AH's (auditory hallucinations) + (positive) commands "to have sex with women...".
Review of Patient #19's plan of care revealed the following identified problems and nursing interventions: 1) alteration in thought process initiated on 10/16/11 - interventions included assess patient's level of orientation; frequently orient to surroundings; assess patient for hallucinations/delusions; encourage patient to report delusions/hallucinations to staff before acting on them; provide low stimulus atmosphere; 2) ineffective individual coping initiated 10/16/11 - no documented evidence of interventions and goals; 3) medication non-adherence initiated 10/16/11 - interventions included educate patient on need and importance of medication compliance; encourage patient to express feelings and concerns around taking psych meds; 4) anxiety initiated 10/16/11 - interventions included assess patient's level of anxiety and physical reactions to anxiety every shift; determine how patient copes with anxiety; encourage patient to report episodes of anxiety; reduce sensory stimuli by maintaining a quiet environment; encourage patient to talk about anxious feelings. Further review revealed Patient #19's care plan was reviewed on 10/17/11 and 10/18/11 without revision. Further review revealed no documented evidence that Patient #19 had a care plan initiated and implemented that addressed aggression, suicide, elopement, and sexually-inappropriate behavior.
Patient #20 Review of Patient #20's medical record revealed she was admitted under PEC on 10/14/11 due to positive auditory hallucinations, positive suicidal ideations, being dangerous to self and others, and being gravely disabled. Review of her CEC signed on 10/15/11 at 10:05am revealed Patient #20 remained a danger to herself and others and was gravely disabled.
Review of Patient #20's History and Physical documented by Physician S33 on 10/15/11 revealed, in part, "...She told our emergency room physician ... that she had auditory hallucinations and thoughts of hurting herself or her family. ... Of note, the patient was also threatening to staff in our emergency room. She did acknowledge to me that she was having command hallucinations to kill herself and others in the past several days. ... The COPE assessment documents that patient had thoughts of killing others with a knife or attempting to obtain a gun.
Review of Patient #20's physician's orders revealed orders for aggression and suicide precautions.
Review of Patient #20's plan of care revealed the following identified problems and nursing interventions: 1) ineffective individual coping initiated 10/14/11 - nursing interventions included teach coping skills; instruct on use of relaxation techniques; assess patient's level of anxiety and depression; assist patient in identifying personal strengths and realistic perceptions; encourage patient to verbalize and express feelings and identify stressors; 2) alteration in thought process initiated 10/14/11 - nursing interventions included assess patient's level of orientation; frequently orient to surroundings; assess patient for hallucinations/delusions; encourage patient to report delusions/hallucinations to staff before acting on them; provide low stimulus atmosphere; encourage same staff to work with patient; utilize genuine matter-of-fact approaches; 3) medication non-adherence initiated 10/14/11 - nursing interventions included identify cause of non-adherent behavior; educate patient on need and importance of medication compliance; encourage patient to express feelings and concerns around taking psych meds; mouth checks for expected cheeking; 4) sleep pattern disturbance initiated 10/14/11 - nursing interventions included assist patient to identify possible underlying cause of insomnia; limit daytime napping by providing activities that promote wakefulness; provide environment conducive to sleep; administer therapeutic measures to promote restful sleep. Further review revealed Patient #20's plan of care was reviewed without revision on 10/15/11, 10/16/11, 10/17/11, and 10/18/11. Further review revealed no documented evidence that Patient #20 had a care plan initiated and implemented that addressed aggression and suicide.
Patient #21 Review of Patient #21's medical record revealed he was PEC'd on 10/11/11 at 4:00pm due to being gravely disabled. Further review revealed he was CEC'd on 10/12/11 at 12:20pm due to being gravely disabled.
Review of Patient #21's physician admit orders of 10/11/11 at 4:40pm revealed an order for suicide and aggression precautions.
Review of Patient #21's "Patient Profile" revealed the following entry on 10/11/11 at 19:57 (7:57pm) by RN S 34" "pt d/c'd (discharged) last week from this unit. Non-compliant with meds and threatening staff and pts at ... group home. Cannot return to live there".
Review of "Additional Nursing Notes" revealed an entry by RN S24 on 10/14/11 at 11:30am of "pt became threatening and agitated, attempting to hit female MHT (mental health tech) and threatening to hit female nurse. Unaccepting of verbal redirection from staff, remains intrusive and cursing frequently at staff and peers...". Review of the "Agitated Behavior Scale" completed by RN S24 on 10/14/11 at 7:00am revealed Patient #21 was exhibiting the following behaviors to an extreme degree: sudden changes of mood; restlessness, pacing, excessive movement; uncooperative, resistant to care, demanding; explosive and/or unpredictable anger; violent and/or threatening violence toward people or property.
Review of Patient #21's plan of care revealed the following identified problems and nursing interventions: 1) ineffective individual coping initiated 10/10/11 (patient was admitted on 10/11/11) - nursing interventions included teach coping skills; instruct on use of relaxation techniques; assess patient's level of anxiety and depression; assist patient in identifying personal strengths and realistic perceptions; encourage patient to verbalize and express feelings and identify stressors; 2) alteration in thought process initiated 10/11/11 - nursing interventions included assess patient's level of orientation; frequently orient to surroundings; assess patient for hallucinations/delusions; encourage patient to report delusions/hallucinations to staff before acting on them; provide low stimulus atmosphere; 3) medication non-adherence initiated 10/11/11 - nursing interventions included identify cause of non-adherent behavior; educate patient on need and importance of medication compliance; mouth checks for expected cheeking; 4) risk for injury (high risk for injury to self) initiated 10/11/11 - nursing interventions included assess and document pt potential for self-harm and/or violence every shift; remove all dangerous objects from pt's environment; implement suicide precautions. Further review revealed Patient #21's care plan had been reviewed without revision on 10/14/11, 10/15/11, 10/16/11, 10/17/11, and 10/18/11. Further review revealed no documented evidence that Patient #21 had a care plan initiated and implemented that addressed aggression and risk for injury to others.
In a face-to-face interview on 10/19/11 at 11:10am, Administrator of Mental Health S4 indicated the hospital's computer system did not have aggression and sexually-inappropriate behavior as choices from which to select for patient problems when initiating the care plan. S4 further indicated the nurses would have to relay the information from shift-to-shift.
In a face-to-face interview on 10/19/11 at 11:50am, Administrator of Mental Health S4 indicated management had identified the problem with the computer system regarding care plans for aggression and sexually-inappropriate behavior. S4 further indicated the problem had been addressed through the IT department, but it had not been addressed through nursing services.
Review of the hospital's policy titled "Special Precautions", number BPN-018 revised May 2011 and submitted as the hospital's current policy for special precautions and observation levels, revealed, in part, "...Special precaution procedures can be initiated by physician or nursing staff when a patient is considered to be an increased risk for harm to self, others or property... Restriction of any patient rights due to special precautions should be addressed in the patient's treatment plan. ... The need for special observation is reflected in the patient's treatment plan or plan of care...". Review of the policy revealed Routine/Unit precautions included a minimum of every 15 minute observations for 24 hours after admission and then every 30 minutes. Review of Level 1 observations revealed 1:1 (one-to-one) staff accompaniment (at arm's length) was required at all times. Review of Level II (2) observations revealed continuous visual observation (Line of Sight) was required. With this level, the patient was required to be within visual range of the assigned staff at all times.
Review of the hospital policy titled "Patient Assessment/Reassessment", number ORGClin/031 revised 08/30/10 and submitted as the current policy for initiation of the plan of care, revealed, in part, "...Inpatient Assessment and Reassessment Timeframes ... Mental/Behavioral Health ... Plan of Care 24 hrs (hours) ... Reassessment .... reassess every 12 hours...".




25065

Based on record review and interviews, the hospital failed to ensure the one-to-one observation of Emergency Department (ED) patients under Physician Emergency Certificate (PEC) provided by the security department was provided according to the ED policy as evidenced by failing to have continuous one-to-one observation documented by the security department staff for 1 of 3 ED patients reviewed who were under PEC (#5) and 2 of 4 random patients observed on 10/20/11 who were under PEC (R1, R2) from a total of 22 sampled patients and 4 random patients. Findings:

Patient #5
Review of Patient #5's medical record revealed she presented to the ED on 08/10/11 at 8:01am with the presenting problem of suicidal ideation. Review of the "ED Triage Assessment" entered on 08/10/11 at 8:32am by RN S10 revealed, in part, "...pt (patient) just abandoned Er (emergency room) after "not getting treated" for left shoulder pain. pt heard by staff stating she would "walk into traffic". pt taken to Room "c", not cooperative. denies SI (suicidal ideation) at this time...". Further review of Patient #5's ED record revealed she was transferred to an inpatient behavioral hospital on 08/10/11 at 2:28pm.
Review of Patient #5's "Physician Emergency Certificate" (PEC) revealed it was signed on 08/10/11 at 8:15am due to Patient #5 being suicidal and dangerous to self. Review of Patient #5's entire ED record revealed no documented evidence of one-to-one visual observation of Patient #5 by a mental health tech (MHT), security representative, or other staff member as required by ED policy for all patients who were under PEC.

Review of documentation by RN S8 on 08/10/11 at 10:21am revealed "security at bedside". Further review revealed an entry by RN S10 on 08/10/11 at 8:30am of "continuous monitoring by security".
In a face-to-face interview on 10/19/11 at 3:40pm, Director of Security S3 indicated security representatives were assigned to the ED and were responsible for the entire ED. He further indicated that on occasion the security representative was assigned to perform one-to-one observation of a patient in an ED room. S3 indicated the security representative used a PEC custody form to document their observations. S3 further indicated the security representatives were not knowledgeable of the "Patient Observation Record" used by the MHTs to document their one-to-one observations.
Review of the monitoring log presented by Director of Security S3 as the PEC custody form used by security representatives when monitoring patients in the ED who were under PEC revealed the following: Section A - date, time, patient name, age, gender, race; Section B - "This section is to be completed during every hand-off between staff"; column for time, report given by, report received by, green wristband in place, check all risk issues that apply (danger to self, danger to others, flight, other). Further review revealed no documented evidence that security representative was required to document other than the time they start observing and the time they hand-off to another representative.
In a face-to-face interview on 10/19/11 at 4:00pm, ED Director S6 indicated one-to-one constant observation meant the employee was to have their eyes on the patient at all times. S6 indicated the ED had no policy that defined what one-to-one observation required. S6 indicated the PEC custody form used by the security staff when they observe patients in the ED did not become a permanent part of the ED patient's medical record. .
Patient R1 Review of Patient R1's PEC revealed he was PEC'd on 10/20/11 at 11:00am due to being suicidal and dangerous to self.
Observation on 10/20/11 at 12:10pm revealed Patient R1 was admitted to room "a" in the ED. Further observation revealed Security Representatives S20 and S21 were assigned to observe Patient R1.
Patient R2 Review of Patient R2's ED record revealed he was PEC'd on 10/19/11 at 2252 (10:52pm) due to being suicidal, dangerous to self, and gravely disabled.
Observation on 10/20/11 at 12:20pm revealed Patient R2 was admitted to room "b" in the ED. Further observation revealed Security Representative S21 and S20 were assigned to provide one-to-one observation of Patient R2.
In a face-to-face interview on 10/20/11 at 12:05pm, Security Representative S21 indicated she and Security Representative S20 were responsible for observing Patients R1 and R2, which meant that they (S20 and S21) were to keep their eyes on Patients R1 and R2 at all times. S21 further indicated she was required to document on the PEC custody form and not the "Patient Observation Record" used by the MHTs.
Review of the hospital's ED policy titled "Physicians Emergency Certificate (PEC)", number MH-02 last revised 03/28/05, last reviewed 03/11, and presented as the current policy for monitoring PEC'd patients in the ED, revealed, in part, "...Purpose: To establish guidelines for a patient who is placed under the Physicians Emergency Certificate. ... Patients that are under PEC, OPC (order of protective custody), CEC (Coroner's Emergency Certificate), and Peace Officers hold are to have 1:1 (one-to-one) observation by Mental Health Tech, Security, or other staff member". The policy failed to define the elements of one-to-one observation to include if the patient was to be on continuous observation, whether the observation required the observer to have eye contact on the patient, the time frame for documentation requirements, the location of the patient when being observed, and the manner of incorporating security representative monitoring in the patient's medical record.

Based on record review and interviews, the hospital failed to ensure the Emergency Department (ED) policies and procedures were revised as necessary based on ongoing monitoring through the hospital's QAPI (quality assessment performance improvement) activities as evidenced by failure to include and track ED patients under Physician Emergency Certificate (PEC) in the QAPI quality monitors. Findings:

Review of the "Adult ECU (emergency care unit) Performance Excellence Dashboard" from January 2011 to present, presented by Director of Quality Management S31 as the current quality indicators for the ED, revealed no documented evidence that the medical records of ED patients under PEC were reviewed to determine that ED policy was followed regarding the one-to-one observation of patients in the ED under PEC.

In a face-to-face interview on 10/20/11 at 2:03pm, Director of Quality Management S31 indicated development of quality indicators for performance improvement focused on high-risk, high-volume, and/or problem-prone areas. S31 confirmed the ED patients under PEC would be considered a high-risk, problem-prone area for the ED. S31 confirmed patients under PEC in the ED was not an area selected for quality improvement, and the identified problem related to the lack of one-to-one monitoring of PEC'd patients had not been identified by the hospital.

Review of the ED records of Patients #5, #7, and #8 revealed no documented evidence that they were observed continuously one-to-one once they were under PEC as required by the hospital's ED policy.

In a face-to-face interview on 10/19/11 at 3:40pm, Director of Security S3 indicated security representatives were assigned to the ED and were responsible for the entire ED. S3 indicated the security representative used a PEC custody form to document their observations of PEC'd patients in the ED. S3 further indicated the security representatives were not knowledgeable of the "Patient Observation Record" used by the MHTs to document their one-to-one observations.
Review of the monitoring log presented by Director of Security S3 as the PEC custody form used by security representatives when monitoring patients in the ED who were under PEC revealed the following: Section A - date, time, patient name, age, gender, race; Section B - "This section is to be completed during every hand-off between staff"; column for time, report given by, report received by, green wristband in place, check all risk issues that apply (danger to self, danger to others, flight, other). Further review revealed no documented evidence that the security representative was required to document observations other than the time they start observing the patient and the time they hand-off to another representative.
In a face-to-face interview on 10/19/11 at 4:00pm, ED Director S6 indicated one-to-one constant observation meant the employee was to have their eyes on the patient at all times. S6 indicated the ED had no policy that defined what one-to-one observation required. S6 indicated the PEC custody form used by the security staff when they observe patients in the ED did not become a permanent part of the ED patient's medical record.
Continuous observations on 10/20/11 from 12:10pm to 12:20pm revealed Random Patients R1 and R2 being observed by Security Representatives S20 and S21. Further observation revealed an occurrence at 12:10pm when S20 had his back to Random Patient R1 and an occurrence at 12:20pm when S21 had her back to Random Patient R2 while she (S21) was speaking to an individual in the hallway.
In a face-to-face interview on 10/20/11 at 12:05pm, Security Representative S21 indicated she and Security Representative S20 were responsible for observing Patients R1 and R2, which meant that they (S20 and S21) were to keep their eyes on Patients R1 and R2 at all times.
Review of the hospital's ED policy titled "Physicians Emergency Certificate (PEC)", number MH-02 last revised 03/28/05, last reviewed 03/11, and presented as the current policy for monitoring PEC'd patients in the ED, revealed, in part, "...Purpose: To establish guidelines for a patient who is placed under the Physicians Emergency Certificate. ... Patients that are under PEC, OPC (order of protective custody), CEC (Coroner's Emergency Certificate), and Peace Officers hold are to have 1:1 (one-to-one) observation by Mental Health Tech, Security, or other staff member". The policy failed to define the elements of one-to-one observation to include if the patient was to be on continuous observation, whether the observation required the observer to have eye contact on the patient, the time frame for documentation requirements, the location of the patient when being observed, and the manner of incorporating security representative monitoring in the patient's medical record.

Review of the hospital's "Patient Safety and Quality PI (performance improvement) Plan", submitted by Director of Quality Management S31 as their current QAPI (quality assessment and performance improvement) plan, revealed, in part, "...To ensure strategic alignment, quality improvement activities emerge from a systematic and organized framework for improvement... This quality improvement framework incorporates four primary activities. Building a culture of patient safety, quality and reliability; Value-added measurement and the assessment of hospital performance through the collection and analysis of data. Identifying opportunities for excellence through active participation (rounding) and team member feedback; Conducting quality improvement and patient safety initiatives and taking action where indicated, including the: design of new services, and/or improvement of existing services. ... Selection of a Performance Indicator. A performance indicator is a quantitative tool that provides information about the performance of the hospital's process, services, functions or outcomes. Selection of a Performance Indicator is based on the following considerations: Relevance to mission ... Relevance to Five Pillars and Strategic Plan ... Organizational importance - whether it addresses important processes that are: high volume, problem prone or high risk...".