HospitalInspections.org

Based on observation and interview the hospital failed to ensure a safe environment. In 6 of 6 areas (Rooms 217 ,218 and their shared bathroom, 219 and 220 and their shared bathroom) environmental hazards were present which could be used for patient hanging. This deficiency has the potential to affect all patients served in this facility.

Findings include:

Observations were made during a tour of the hospital on 01/28/15 at 9:00 AM. Rooms numbered 217, 218, 219 and 220 had doors with hinges from which a ligature (a thing used for tying or binding something tightly) could be affixed and shared two bathrooms which contained open grab bars which would also allow attachment of a ligature.

Per interview with DON (Director of Nursing) A on 01/28/15 at 10:00 AM the facility is in the midst of remodeling and plans to change hinges and grab bars, the rooms observed are being used for inpatients.

On 01/28/15 at 10:30 DON stated that they knew of the present hazards of the hinges and grab bars and their correction was planned for 2015.

Based on record review and interview the hospital failed to use least restrictive measures to ensure safety. In 3 of 3 (25,26 and 27) restraint/seclusion records reviewed when physical restraint was initiated before seclusion. This has the potential to affect all patients served by this facility.

Findings include:

Staff education material on restraint and seclusion was provided by DON A on 01/27/15 at 9:30 AM. The manual was entitled; "Care 2 Learn Online Education for Healthcare. Title of activity: Restraints, Seclusion, and the 1 hour Evaluation (1367)" No date is listed.

On page 11 of the manual under the section titled; "Least-to-Most Restrictive" it states; "When choosing a restraint, the least restrictive yet appropriate method must be considered. The least-to-most restrictive interventions are: medication, seclusion, and mechanical restraints." Additionally under the section titled "Mechanical Restraints" the manual states; "Mechanical restraints are the most restrictive form of intervention and may be used in situations where staff can remain safely with the patient and offer calming strategies."

Hospital policy entitled; "Seclusion/Restraints" dated 05/07/2012 was reviewed on 01/27/15 at 2:00 PM, it states: "In an emergency situation it (restraint/seclusion) will be used in order to to protect the patient and others from injury, and only as a last intervention when less restrictive/intrusive interventions have been attempted and failed.....The treatment plan will specify less restrictive measures to use first as appropriate for each patient. Seclusion/restraint will not be used as punishment of the patient, for staff convenience, or as a substitute for less restrictive interventions."

Per Pt. (patient) #25's medical record, reviewed on 01/27/2015 at 10:00 AM, the facility placed Pt. #25 in restraints on 11/25/2014 for "assaultive, destructive" behavior. There is no documentation of the staff using any type of less restrictive measures, up to and including seclusion, before placing the patient in restraints per facility policy.

Per Pt. #26's medical record, reviewed 01/27/2015 at 10:00 AM, the facility placed Pt. #26 in restraints on 8/17/2014 for "assaultive, combative" behaviors. There is no documentation of the staff using seclusion as a less restrictive method prior to placing the patient in restraints.

Per Pt. #27's medical record, reviewed 01/27/2015 at 10:00 AM, the facility placed Pt. #27 in restraints on 10/5/2014 and 10/6/2014 for "assaultive, destructive" behaviors. There is no documentation of the staff using seclusion as a less restrictive method prior to placing the patient in restraints.

Per interview with DON A on 01/27/15 at 11:00 AM the facility had approximately 14 episodes requiring restraints or seclusion over the past year and they all resulted in physical restraint with no intervening seclusion. A stated that seclusion is less restrictive than restraint.

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Based on record review and interview the facility failed to update the patient plan of care to reflect the use of restraints in 3 of 3 restrained patient medical records (#25, #26, #27). This deficiency has the potential to affect all patients served by the facility.

Findings include:

Facility policy "Seclusion/Restraints" dated 5/7/2014, reviewed 1/28/2015 at 9:00 AM, states in part: "RN Duties: ...4. Ensure that any use of seclusion/restraint and least restrictive approaches is included in the care plan and is reviewed and discussed by the treatment team... 5. Ensure that all patients who are placed in seclusion/restraint have a problem on their treatment plan addressing that need with outlined interventions and goals..."

Per Pt. #25's MR, reviewed 1/28/2015 at 8:05 AM, the facility placed Pt. #25 in restraints on 11/25/2014 for "assaultive, destructive" behavior. The treatment plan does not include a problem, goal or approach to address the need for restraint.

Per Pt. #26's MR, reviewed 1/28/2015 at 8:30 AM, the facility placed Pt. #26 in restraints on 8/17/2014 for "assaultive, combative" behaviors. The treatment plan does not include a problem, goal or approach to address the need for restraint.

Per Pt. #27's MR, reviewed 1/28/2015 at 8:50 AM, the facility placed Pt. #27 in restraints on 10/5/2014 and 10/6/2014 for "assaultive, destructive" behaviors. The treatment plan does not include a problem, goal or approach to address the need for restraint.

RN Manager B stated at the time of the above findings that staff "should have added the restraints as part of the care plan."

Based on record review and interview the facility failed to evaluate restrained patients with violent behaviors within 1 hour in 3 of 3 restrained patient records reviewed (#25, #26, #27). This deficiency has the potential to affect all patients served by the facility.

Findings:

Facility policy "Seclusion/Restraints" dated 5/7/2014, reviewed 1/28/2015 at 9:00 AM, states in part: "RN Duties: ...3. Within one hour of the application of restraints, a registered nurse, who has been trained in restraint use and seclusion or a physician...will conduct a face-to-face evaluation. This will evaluate the patient's current medical and behavioral condition, reaction to the restraints or seclusion, and the need to continue or terminate the restraints or seclusion...This evaluation will be documented in the patient's medical record."

Per Pt. #25's MR, reviewed 1/28/2015 at 8:05 AM, the facility placed Pt. #25 in restraints on 11/25/2014 for "assaultive, destructive" behavior. The MR does not include documentation of a face-to-face evaluation within 1 hour of restraint application.

Per Pt. #26's MR, reviewed 1/28/2015 at 8:30 AM, the facility placed Pt. #26 in restraints on 8/17/2014 for "assaultive, combative" behaviors. The MR does not include documentation of a face-to-face evaluation within 1 hour of restraint application.

Per Pt. #27's MR, reviewed 1/28/2015 at 8:50 AM, the facility placed Pt. #27 in restraints on 10/5/2014 and 10/6/2014 for "assaultive, destructive" behaviors. The MR does not include documentation of a face-to-face evaluation within 1 hour of restraint application.

RN Manager B stated at the time of the above findings that the RN documents the patient condition while in restraints on the "observation codes" sheet, but is not aware of the nurse or MD completing a 1 hour face-to-face evaluation.

Based on record review and interview the hospital failed to include all services in 1 of 1 QAPI (Quality Assurance Performance Improvement) programs. This deficiency has the potential to affect all patients served by the hospital.

Findings include:


Per review on 01/27/15 at 10:00 AM of Quality Assurance/Performance Improvement Plan (effective date 01/01/15); "All quality assurance/performance improvement reports and findings, as compiled by each department, will be submitted to the Quality Assurance/Performance Improvement Committee on a quarterly basis."

Per review of minutes from quarterly meetings on 01/27/15 at 10:30 AM of the Quality Assurance/Performance Improvement Committee data was not submitted from all hospital departments including; Dietary, Activity Therapy, Housekeeping and Laboratory.

Per interview with QAPI Director E on 01/26/15 at 1:15 PM, data from the following services have not been included in the Quality Program; Activity therapy, Dietary, Housekeeping. Per Director E, not all departments have contributed data for review by the Quality Program.

Based on record review and interview the facility failed to ensure complete care plans were developed. In 23 of 30 medical records (MR) reviewed (#1,2,3,5,7,8,9,10,11,12,13,14,15,16,17,20,21,25,26,27,28,29,30) and 1 of 1 interviews careplans were not complete. This deficiency has the potential to affect all patients served at the facility.

Findings include:

Pt. #2's medical record was reviewed on 01/27/15 at 11:45 AM, the record contains a care plan for the problems of Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; Partner/marital conflict and Depressed Behavior. Goals and approaches are not individualized and do not offer concrete examples of expected outcomes or specific patient driven plans.

Pt. #20's medical record was reviewed on 01/27/15 at 1:40 PM, the record contains a care plan for the problem of "suicidal thinking". Goals and approaches are not individualized and do not offer concrete examples of expected outcomes.

Pt. #21's medical record was reviewed on 01/27/15 at 1:45 PM, the record contains a care plan for the problems of Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; Suicidal thinking and Non-compliance of med's/treatment. Goals and approaches are not individualized and do not offer concrete examples of expected outcomes or specific patient driven plans.

Pt. #30's medical record was reviewed on 01/27/15 at 09:45 AM, the record contains a care plan for the problems of Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; anxiety and potential for elopement. Goals and approaches are not individualized and do not offer concrete examples of expected outcomes or specific patient driven plans.


Per interview with RN F on 01/27/15 the care plans in the medical record are considered the complete treatment plan.



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Pt. #1's MR, reviewed 1/27/2015 at 8:20 AM, includes a nursing care problem list of Auditory Hallucinations; Discharge Planning; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; Suicidal Thinking and Psychiatric Services. Goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #1's hospital stay.

Pt. #3's MR, reviewed 1/27/2015 at 8:40 AM, includes a nursing care problem list of Non-Compliance of Tx; Suicidal Thinking; Misuse of Drugs/Substances; Discharge Planning; Psychiatric Services and Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities. Goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #3's hospital stay.

Pt. #15's MR, reviewed 1/27/2015 at 9:35 AM, includes a nursing care problem list of Depressed Behavior; Suicidal Thinking; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; and Discharge Planning. Goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #15's hospital stay.

Pt. #16's MR, reviewed 1/27/2015 at 10:40 AM, includes a nursing care problem list of Depressed Behavior; Anxiety; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; and Potential for Alcohol Withdrawal. Goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #16's hospital stay.

Pt. #17's MR, reviewed 1/27/2015 at 11:15 AM, includes a nursing care problem list of Family Conflict; Discharge Planning; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; Depressed Behavior; Anxiety and Psychiatric Services. Goals and approaches are not unique to the patient. Progress notes do not include documentation of the approaches used to meet treatment goals nor progress made toward meeting goals during Pt. #17's hospital stay.

Pt. #25's MR, reviewed 1/28/2015 at 8:05 AM, includes a nursing care problem list of Discharge Planning; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities; Misuse of Drugs/Substances and Psychiatric Services. Overall goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #25's hospital stay.

Pt. #26's MR, reviewed 1/28/2015 at 8:30 AM, includes a nursing care problem list of Delusional Thinking; Potential for Elopement; Discharge Planning; Psychiatric Services; Psychotropic Drug Use; Potential for Poorly Controlled Blood Sugars; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities. Overall goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #26's hospital stay.

Pt. #27's MR, reviewed 1/28/2015 at 8:50 AM, includes a nursing care problem list of Potential for Elopement; Auditory Hallucinations; Suicidal Thinking; Discharge Planning; Psychiatric Services; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities. Overall goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #27's hospital stay.

Pt. #28's MR, reviewed 1/28/2015 at 9:15 AM, includes a nursing care problem list of Suicidal Thinking; Depressed Behavior; Discharge Planning; Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities and Psychiatric Services. Overall goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #28's hospital stay.

Pt. #29's MR, reviewed 1/28/2015 at 9:30 AM, includes a nursing care problem list of Suicidal Thinking; Misuse of Drugs/Substances; Discharge Planning; Psychiatric Services and Occupational Therapy: lack of assertive communication skills, lack of appropriate leisure activities. Goals and approaches are not unique to the patient, intervention frequency is not specified (i.e. daily, every shift, etc.). Progress notes do not include comprehensive documentation of the approaches used to meet treatment goals nor provide a concise picture of progress made toward meeting goals during Pt. #29's hospital stay.


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Patients (5, 7, 8, 9, 10, 11, 12, 13, 14) MR review 01/26/2015 and 01/27/2015 show care plans documented on arrival. Plans are generic and medically focused. No reassessment or progression towards long or short term goals throughout patient stay. Per Policy and Procedure: Treatment Plans, dated August 25, 2014 under Responsibility/All Staff: the action stated; Work on prioritized goals. When goals are met, ensure the care plan or progress notes reflect attainment. Policy received by Nurse Manager Staff B on 01/27/2015. Reviewed charts with Nurse Manager Staff B 01/27/2015.

Pt # 5 admitted 01/21/2015, currently inpatient status, MR review on 01/26/2015, care plan initiated on admission 01/21/2015 with nursing identifying Post Trauma Response and Potential for Seizure activity both with short term goal target date of 01/23/2015 with no evaluation or reassessment documented. No other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.

Pt # 7 admitted 12/23/2014, discharged 01/02/2015, MR review on 01/26/2015, care plan initiated on admission 11/25/2014 with nursing progress notes dated 11/24/2014 documenting Pt with anxiety, yet no care plan for anxiety initiated, care plans identified for Pt on 12/23/2014: Discharge Planning and Occupational therapy. No other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.
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Pt # 8 admitted 12/17/2014, discharged 12/22/2014, MR review on 01/26/2015, care plan initiated on admission 12/27/2014 with nursing identifying Partner/Marital Conflict with documented note by RN on 12/21/2014 problem reviewed. Suicidal Thinking documented note by RN on 12/19/2014 problem resolving, other problems identified: Anxiety, Depressed Behavior with no evaluation documented. No other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.

Pt # 9 admitted 12/03/2015, discharged 12/08/2015, MR review on 01/27/2015, care plan initiated on admission 11/24/2014 with nursing identifying Potential for Poorly Controlled Blood Sugars, updated in progress notes, and Potential for Alcohol Withdrawal, Suicidal Thinking, no other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals, other than documented blood sugars.

Pt # 10 admitted 11/17/2014, discharged 11/26/2014, MR review on 01/26/2015, care plan initiated 11/27/2014 with nursing identifying Misuse of Drugs/Substances, Family Conflict Improved/Ongoing, Anxiety, no other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.

Pt # 11 admitted 11/24/2014, discharged 12/01/2015, MR review on 01/27./2015, care plan initiated on admission 11/24/2014 with nursing identifying Suicidal Thinking, Depressed Behavior, no other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.

Pt #12 admitted 12/05/2015, discharged 12/10/2015, MR review on 01/27/2015, care plan initiated on admission 12/05/2015 with nursing identifying Suicidal Thinking as only nursing problem with no other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.

Pt #13 admitted 11/24/2014, discharged 12/02/2015, MR review on 01/27/2015, care plan initiated on admission 11/24/2014 with nursing identifying Suicidal Thinking, Family Conflict, Poor Frustration Tolerance as nursing problems with no other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.

Pt #14 admitted 12/13/2015, discharged 12/17/2015, MR review on 01/27/2015, care plan initiated on admission 12/13/2015 with nursing identifying Poor Frustration Tolerance, Family Conflict as nursing problems with no other problems identified or resolved throughout stay. Care plans not individualized therefore no documentation observed for progression towards short or long term goals.

Based on record review and interview with facility staff the hospital failed to ensure that patient discharge summaries are completed within designated timeframe's. In 11 of 21 closed medical records (MR) reviewed (#3,15,16,17,20,21,22,25,26,27,30), discharge summaries were not completed within 30 days per facility policy. This deficiency has the potential to affect all patients served by the facility.

Findings include:

Facility policy "Audit of Admission Unit (Hospital) Medical Records" dated 2/25/2004, reviewed on 1/26/2015 at 1:05 PM, states in part: "The Health Information Manager or Medical Records Technician will do a complete medical record audit on each record within 30 days of discharge. All items which are deficient will be flagged...it is expected that the corrections will be made and the pages will be returned to Medical Records within one week."

Patient #3 was discharged on 12/05/14, a discharge summary was not dictated, transcribed and entered into the medical record until 01/20/15. MR reviewed 01/28/15 at 9:00 AM.

Per Pt. #15's MR, reviewed 1/27/2015 at 9:35 AM, Pt. #15 was discharged from the facility on 12/10/2014. HIM (Health Information Management) Manager E stated at the time of the MR review the discharge summary had not yet been transcribed and was not included in the MR.

Per Pt. #16's MR, reviewed 1/27/2015 at 10:40 AM, Pt. #16 was discharged from the facility on 12/10/2014. HIM Manager E stated at the time of the MR review the discharge summary had not yet been transcribed and was not included in the MR.

Per Pt. #17's MR, reviewed 1/27/2015 at 11:15 AM, Pt. #17 was discharged from the facility on 12/17/2014. HIM Manager E stated at the time of the MR review the discharge summary had not yet been transcribed and was not included in the MR.

Patient #20 was discharged on 11/25/14, a discharge summary was not dictated until 01/13/15 and not transcribed and entered into the medical record until 01/20/15.

Patient #21 was discharged on 12/01/14, a discharge summary was not dictated until 01/19/15 and not transcribed and entered into the medical record until 01/21/15.

Patient #22 was discharged on 12/23/14, a discharge summary was not dictated, transcribed and entered into the medical record until 01/27/15.

Pt. #25's MR, reviewed 1/28/2015 at 8:05 AM, reveals a discharge date of 12/1/2014. The discharge summary is dated 1/19/2015, greater than 30 days after discharge.

Pt. #26's MR, reviewed 1/28/2015 at 8:30 AM, reveals a discharge date of 8/27/2014. The discharge summary dictation is dated 9/22/2014, transcription dated 9/26/2014 and is signed by the physician on 10/20/2014, more than 30 days after discharge.

Pt. #27's MR, reviewed 1/28/2015 at 8:50 AM, reveals a discharge date of 10/6/2014. The discharge summary transcription is dated 11/6/2014 and is signed by the physician on 11/24/2014, more than 30 days after discharge.

Per Pt. #30's MR, reviewed 1/28/2015 at 10:00 AM, Pt. #30 was discharged from the facility on 12/15/2014. HIM Manager E stated at the time of the MR review the discharge summary had not yet been transcribed and was not included in the MR.

During an interview on 1/26/2015 at 11:45 AM, HIM Manager E stated it is expected that all medical records are complete within 30 days after discharge and it is the responsibility of the HIM transcriptionist to ensure the records are complete.

Based on observation, record review and interview the facility failed to dispose of outdated medications and biologicals in 2 of 2 medication storage areas (medication room and emergency code cart).

Findings include:


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Policy "Pharmaceutical Services-Use of Medication" dated 8/13/2014, reviewed 1/26/2015 at 4:00 PM, states in part "Pharmacy will audit the Medication Room during their visit and check for any potential expired medication...Bacteriostatic NS and Water for injection should be dated when opened and discarded in 28 days after first use."

During observations of the nursing unit on 1/26/2015 at 10:30 AM, the emergency code cart contained patient-specific glucogon with an expiration date of 7/5/2014. The medication room contained an opened, unlabeled bottle of Bacteriostatic NS, an opened, unlabeled bottle of sterile water and two opened, unlabled bottles of hydrogen peroxide with expiration dates of 8/2011 and 4/2014.

RN Manager B stated at the time of the observations that the expired medication found in the emergency code cart "should not be there" and that pharmacy is responsible to remove expired medications from the medication room.

Based on observation and interview, the facility failed to ensure that 4 of 5 kitchen dietary staff on duty (K,M,N,O) received required instruction in preparation and serving of food, food safety and infection control. This deficiency has the potential to affect all patients served by the facility.

Findings include:

01/28/2015 at 9:00 AM, interview of 5 of 5 kitchen staff on duty (Staff K, L, M, N, O) only 1 staff member (Staff L) had any formal food safety training with evident certification. Staff members, K, M, N, O described no formal or recent training and that they learned on the job from other employee's when they were hired. 01/27/2015 at 9:10 AM, Staff K (31 years) stated, "I never had any specialized training". 01/28/2015 at 9:10 AM, Staff L (19 years) stated, "Completed Professional Safe Food Handlers Course - 11/2014". 01/28/2015 at 9:05 AM, Staff M (34 years) stated, "no programs offered, use to have dietician that gave inservices with mini tests, but we haven't had a dietician for the last 4 years". 01/28/2015 at 9:00 AM, Staff N (14 years) stated, "I went to dietary school at St. Joseph's Hospital 30 years ago, no training since". 01/28/2015 at 9:15 AM, Staff O (32 years) stated, "I had no certification courses, just learned on the job". All interviews validated by Director of Food Service Manager, Staff D.


01/26/2015 at 10:30 AM, observation of kitchen sanitation found serving utensils (forks, knives, spoons) in containers located on the bottom shelf (6 inches above floor) of food service cart. Per interview with Food Service Dir Staff D stated " yes, those utensils are too close to the floor and can get splashed when they mop the floor".

01/27/2015 at 10:35 AM, observation and interview with Staff N regarding sanitation process of cleaning rags, Staff N stated, "we just keep the rags in the drawer and use whatever cleaning product (unable to specifically identify product used) to wash down the tables and kitchen areas". No chemical sanitation process in place. Food Service Director Staff D stated, " yes, we need to use the red/green bucket process with the sanitizer in it".

Based on a tour of the facility with a facility staff between January 26th, 2015; Surveyor #14105 observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients; the Condition of Participation is not met. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

K-tags cited were as follows:
K-67: Hvac system
K147: Electrical system

These deficient practices were confirmed by observation and interviews with Staff -00- Maintenance Supervisor at the time of discovery.

Refer to the full description and findings in the specific K-tags, listed above, within the Life Safety Code survey report.

Based on a tour of the facility with a facility staff between January 26th, 2015; Surveyor #14105 observed that the hospital failed to be constructed, arranged, or maintained to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients, the Life Safety from Fire is not met. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

K-tags cited were as follows:
K-67: Hvac system
K147: Electrical system

These deficient practices were confirmed by observation and interviews with Staff -00- Maintenance Supervisor at the time of discovery.

Refer to the full description and findings in the specific K-tags, listed above, within the Life Safety Code survey report.

Based on observation and interview the facility failed to ensure patient safety equipment is monitored and maintained in 2 of 2 devices (AED and suction machine). This deficiency has the potential to affect all patients served by this facility.

Findings:

During an observation of the nursing unit on 1/26/2015 at 10:30 AM, the emergency code cart contained an AED (automated external defibrillator) and a suction machine.

RN Manager B stated at the time of the observation that staff is doing weekly checks of the equipment to ensure that the AED and suction machine is functioning properly. The facility was unable to produce documented evidence surrounding the routine safety and quality monitoring of this equipment.

Based on observation, record review and interview the facility failed to monitor the temperature of refrigerated pharmaceuticals per recommended guidelines in 1 of 1 medication refrigerator. This deficiency has the potential to affect all patients served by the facility.

Findings include:

Facility policy "Pharmaceutical Services-Use of Medications" dated 8/13/2014, reviewed 1/26/2015 at 4:00 PM, contains an attachment titled "Common Storage Parameter Terminology". Regarding temperature control of medications, the attachment states "Temperature excursion: Period of time at which a product is outside of its recommended or labeled storage temperature; this time should be kept to a minimum...according to CDC Guidelines, refrigerators and freezers used in storing vaccines should have their temperatures monitored at least twice daily."

On 1/26/2015 at 10:30 AM, the medication refrigerator-freezer temperature log, posted on the exterior of the refrigerator, contained a designated space for once daily temperature monitoring. The January 2015 log did not contain temperatures of the refrigerator or freezer on 1/5/2015, 1/6/2015, 1/13/2015, 1/14/2015, 1/15/2015, 1/24/2015 and 1/25/2015. The refrigerator contained medications, including vaccines.

RN Manager B stated at the time of the observation that staff "should" be monitoring and documenting the medication refrigerator and freezer temperatures daily.

Based on staff interview the facility failed to designate qualified personnel to oversee its infection control program in 1 of 1 infection control program. This deficiency has the potential to affect all patients served by this facility.


Findings include:

During an interview with DON A on 1/27/2015 at 2:30 PM, DON A stated that DON A and RN Manager B share infection control responsibilities. Responsibilities include collection of data and reporting quarterly to the medical staff committee. DON A confirmed having no specialized training, certification or experience specific to infection control outside of the facility's mandatory annual training required for all staff members.

RN Manager B stated during an interview on 1/27/2015 at 3:15 PM that RN Manager B had no specialized training or certification in infection control prevention other that the facility's annual training.

Based on observation, record review and interview the facility failed to ensure staff and patient protection from potentially infectious organisms through proper hand hygiene in 1 of 1 staff observed (Tech I). This deficiency has the potential to affect all patients served by this facility.

Findings include:

Facility policy "Handwashing-Routine" dated 1/12/2010, reviewed on 1/27/2015 at 4:00 PM, states in part: "Gloves must be changed/removed: If moving onto another task. If entering an area considered to be clean..."

During an observation of the nursing unit on 1/27/2015 at 1:35 PM, Tech I walked approximately 30 feet down a common hallway after exiting a patient room. Tech I was observed wearing gloves with no other materials or objects in hand. Tech I stated, "I was just removing dirty bedding" and proceeded to remove the gloves. Tech I did not perform hand hygiene after removing the gloves.

During an interview with DON A on 1/27/2015 at 2:30 PM, DON A stated that staff is expected to perform hand hygiene before and after direct patient contact, during tray pass and upon entering and exiting the unit. DON A stated Tech I "should not have been walking the hallway with dirty gloves."

Based on record reviews, interviews, and other document reviews, the facility failed to:

I. Ensure that social service assessments included conclusions and recommendations that described anticipated social work roles in treatment and discharge planning for eight of eight active sample records (A, B, C, D, E, F, G and H). This failure results in a lack of professional social work treatment services and lack of input to the treatment team for eight of eight active patients. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H). Specifically, the MTPs did not include the following: (1) a substantiated diagnosis (Refer to B120); (2) specific individualized active treatment interventions (Refer to B122); and (3) the name of the staff person responsible for implementing the treatment (Refer to B123). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that sufficient active treatment measures and care were provided to 6 of 8 active sample patients (A, B, C, D, F and G) in order to move the patient to a higher level of functioning. Failure to provide a treatment setting that provides sufficient active treatment denies the patient the care required to ensure his/her optimal improvement. (Refer to B125-I)

IV. Ensure that seclusion and restraint measures were used as a least restrictive intervention in active treatment and that documentation of seclusion and restraint included a comprehensive face-to-face evaluation of the patient ' s status within one hour of initiation of a seclusion and/or restraint (S&R) procedure. Failure to systematically treat the patient in the least restrictive manner violates patients' dignity and respect. (Refer to B125-II)

Based on record reviews, interviews, and policy review, the facility failed to ensure that social service assessments included conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for eight of eight active sample records (A, B, C, D, E, F, G and H). This results in a lack of professional social work treatment services and lack of input to the treatment team for eight (8) of eight (8) active patients.

Findings include:

A. Record Reviews

1. Patient A- The psychosocial assessment dated 1/21/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

2. Patient B- The psychosocial assessment dated 12/24/14 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

3. Patient C- The psychosocial assessment dated 1/26/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

4. Patient D- The psychosocial assessment dated 1/21/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

5. Patient E- The psychosocial assessment dated 1/22/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

6. Patient F- The psychosocial assessment dated 1/22/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

7. Patient G- The psychosocial assessment dated 1/22/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.

8. Patient H- The psychosocial assessment dated 1/21/15 does not include conclusions or recommendations related to the anticipated role of the social worker in active treatment.


B. Staff Interviews

1. SW1 stated in an interview on 1/27/15 at 11:50 a.m. that the data collected for the social service assessment is often obtained while sitting in on the psychiatrist's psychiatric evaluation. "Sometimes I do not meet with the patient in addition to the psychiatrist's psychiatric evaluation."

2. The Client Services Manager (Director of Social Services) stated in an interview on 1/27/15 that the current Social History policy dated 8/24/11 "needs to be updated." She stated that psychosocial data is no longer collected in the manner described in the policy. When reviewing the psychosocial assessments with the Director of Social Work, the surveyor was told that the "Referral" section was the place on the psychosocial assessment form where conclusions and recommendations would appear. However, the Director of Social Services further stated that what was written in this section "applies to the whole treatment team and not specifically to the role of the social worker." She stated that the primary role of the social worker at this facility is discharge planning and utilization review calls.

3. The Treatment Director stated in an interview on 1/27/15 that social work summaries and recommendations are often found on the treatment plan rather than in the psychosocial assessment.

C. Policy Review

1. The policy entitled Social History (Comprehensive) (8/24/11) states that the Social History must include "Assessment and Discharge Planning."

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans included substantiated diagnosis that could serve as a basis for treatment of six (6) of eight (8) active sample patients (B, D, E, F, G and H.) In addition, two (2) of eight (8) active sample patients (A and C) had a diagnosis listed on their Master Treatment Plans but it did not serve as a focus of treatment. This practice compromises the staff's ability to deliver clinically focused treatment.

Findings include:

A. Record Review

The Master Treatment Plans (MTPs) for the following active sample patients were reviewed (dates of MTPs in parentheses): B (1/26/15); D (1/26/15); E (1/26/15); F (1/26/15); G (1/26/15); and G (1/26/15). The review revealed no substantiated diagnosis written in the Master Treatment Plans.

B. Interview

1. In an interview on 1/27/15 at approximately 08:35 a.m., the Registered Nurse (RN I) acknowledged that the substantiated diagnosis were not included in the Master Treatment Plans of the six (6) active patients.

2. In an interview on 1/27/15 at approximately 1:05 p.m., the Nursing Director acknowledged that there was no substantiated diagnosis written in the Master Treatment Plans.

C Policy Review

Facility policy titled "Treatment Plans" effective 5/3/05 and updated 8/25/14, stated: "Complete substantiated diagnosis and update as needed when treatment plan is completed." The facility failed to follow their own policy in regards to treatment plans. The policy did not provide the clinical staff with sufficient information to guide them in writing a comprehensive, integrated, and individualized approach to a multidisciplinary treatment.

Based on medical record review, the facility failed to develop Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H.) that clearly delineated staff interventions to address the patients' individual problems and assist them to accomplishment their treatment objectives. The interventions for the patients were routine generic tasks for specific disciplines, identified as treatment interventions, and failed to specify the treatment modalities that were to be used for the interventions.

These deficiencies resulted in lack of guidance for staff in providing individualized patient treatment that is purposeful and consistent.

Findings include:

I. Record Review

1. Patient A: Treatment Plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Behavioral Symptoms"

Psychiatrist: "Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN. Offer daily sessions 1:1 or with tx (treatment) team to review s/sx (signs and symptoms) of (name of patient) progress with symptoms, and tx[sic] options for the same. Provide input into discharge planning. Provide consult as requested by psychologist." These were routine required tasks.

Nursing: "Nurse will educate on medications and report effectiveness of any side effects of medications." These were routine nursing functions that would be provided for any patient regardless of presenting symptoms.

Social Services: "Arrange for discharge planning conference. Set up court hearing proceedings as needed with county of responsibility."

Occupational Therapy: No interventions documented.

2. Patient B: Treatment plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Depressed Behavior."

Psychiatrist: "Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN, offer daily sessions 1:1 or with tx[sic] team to review s/sx[sic] of (name of patient) progress with symptoms, and tx[sic] options for the same. Provide input into discharge planning. Provide consult as requested by psychologist." These were routine required tasks.

Nursing: "Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching. Provide support and reassurance and will verbally refocus (name of patient) to positive aspects of her life. Staff will help (name of patient) learn ways to resolve or cope with negative aspects of her life. Reinforce and praise (name of patient) for positive interactions or statements about her future." These were routine required tasks.

Occupational Therapy: " Offer him/her a few projects to choose from. Provide 1:1 time along with group and individual activities. Occupational therapy groups reviewed and identified for patient use." These were routine required tasks.

Social Services: No interventions documented.

3. Patient C: Treatment plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Behavioral Symptoms."

Psychiatrist: "Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN, offer daily sessions 1:1 or with tx[sic] team to review s/sx[sic] of (name of patient) progress with symptoms, and tx[sic] options for the same. Provide input into discharge planning. Provide consult as requested by psychologist." These were routine required tasks.

Nursing: "Provide 1:1 time along with group and individual activities. Calendar posting reviewed with patient and encouraged attendance." These were routine required tasks.

Social Services: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with the patient and support person. Ensure access to services." These were routine required tasks.

Occupational Therapy: "Using activity preferences and interview of patient to document patient interests. Occupational therapy groups reviewed and identified for patient use. Group calendar posting reviewed with patient and encouraged to attend in conjunction with treatment needs." These were routine required tasks.

4. Patient D: Treatment plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Suicidal Thinking."

Psychiatrist: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person. Ensure access to services." These tasks are functions and responsibilities of social services rather than functions and responsibilities of the psychiatrist.

Nursing: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person. Ensure access to services." These tasks are functions and responsibilities of social services rather than functions and responsibilities of nursing services.

Social Services: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person. Ensure access to services." These were routine required tasks.

Occupational Therapy: "Occupational therapy groups reviewed and identified for patient use. Group calendar posting reviewed with patient and encouraged to attend in conjunction with treatment needs." These were routine required tasks.

5. Patient E: Treatment plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Misuse of Drugs."

Psychiatrist: "Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN, offer daily sessions 1:1 or with tx[sic] team to review s/sx[sic] of (name of patient) progress with symptoms, and tx[sic] options for the same. Provide input into discharge planning. Provide consult as requested by psychologist." These were routine required tasks.

Nursing: "Assess for suicidal risk on admission by assessing if there is a history of suicidal attempts, intent with direct questions that clarify, does he/she have a plan, and can he/she act on this plan or have a method and determination how lethal the plan is and how accessible the method is. Encourage (name of patient) to communicate feelings to staff and reassure him/her he/she is in a safe place." These were routine required tasks.

Social Services: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person. Ensure access to services." These were routine required tasks.

Occupational Therapy: " Provide 1:1 time along with group and individual activities. Occupational therapy groups reviewed and identified for (name of patient) use. Group calendar posting reviewed with patient and encouraged to attend in conjunction with treatment needs." These were routine required tasks.

6. Patient F: Treatment plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Depressed Behavior"

Psychiatrist: "Allow discussion time to vent regarding what conflicts are in the relationship and the effects on self/family. Offer groups for conflict resolution, stress management, problem solving and coping skills." These were routine required tasks.

Nursing: "Nursing staff will provide support and reassurance and will verbally refocus patient to positive aspects of his or her [sic] life. Staff will help (name of patient) learn ways to resolve or cope with negative aspects of his or her [sic] life. Reinforce and praise (name of patient) for positive interactions or statements about self of (name of patient) future." These were routine required tasks.

Social Services: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person." These were routine required tasks.

Occupational Therapy: "Provide 1:1 time along with group and individual activities. Using activity preferences and interview of patient to document patient interests. Occupational therapy groups reviewed and identified for patient use. Group calendar posting reviewed with patient and encouraged to attend in conjunction with treatment needs." These were routine required tasks.

7. Patient G: Treatment plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Auditory Hallucinations."

Psychiatrist: "Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN, offer daily sessions 1:1 or with tx[sic] team to review s/sx[sic] of (name of patient) progress with symptoms, and tx[sic] options for the same. Provide input into discharge planning. Provide consult as requested by psychologist." These were routine required tasks.

Nursing: "As appropriate nursing staff will encourage group attendance or offer individual group time. Nursing staff will give positive reinforcement for staying focused on the topic or conversation during 1:1 time. Nursing staff will provide decreased stimulations, verbal redirection, and refocusing to reality issues. If tormenting hallucinations or paranoid thoughts are present nursing staff will express understanding of patient's distress, give reassurance, suggests interventions and if indicated, offer prn (as necessary) meds to relieve distress." These were routine required tasks.

Social Services: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person." These were routine required tasks.

Occupational Therapy: " Provide 1:1 time along with group and individual activities. Using activity preferences and interview of patient to document patient interests. Occupational therapy groups reviewed and identified for patient use. Group calendar posting reviewed with patient and encouraged to attend in conjunction with treatment needs." These were routine required tasks.

8. Patient H: Treatment plan dated 1/26/15 contained the following routine and generic discipline functions for identified problem "Cognitive Impairment."

Psychiatrist: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person. Ensure access to services." These tasks are functions and responsibilities of social services rather than functions and responsibilities of the psychiatrist.

Nursing: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with (name of patient) legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person." These tasks are functions and responsibilities of social services rather than functions and responsibilities of nursing.

Social Services: "Arrange for discharge planning conference. Set up court proceedings as needed with county of responsibility. Review with patient legal status and expectations of hospital stay in collaboration with psychiatry. Define roles and expectations of discharge with (name of patient) and support person." These were routine required tasks.

Occupational Therapy: "Provide 1:1 time along with group and individual activities. Using activity preferences and interview of patient to document patient interests. Occupational therapy groups reviewed and identified for patient use. Group calendar posting reviewed with patient and encouraged to attend in conjunction with treatment needs." These were routine required tasks.

Based on record reviews and interviews, the facility failed to ensure that the name of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans of eight (8) of eight (8) sample patients (A, B, C, D, E, F, G and H, ). Instead the Master Treatment Plan (MTP) identified the staff discipline as the responsible party for each treatment approach. This practice results in the facility's inability to monitor staff accountability for specific treatment modalities.

Findings include:

A. Record Review

1. Patient A (admitted 1/21/15; MTP 1/21/15)

"Approach: Provide opportunity to attend coping skills group
Discipline: Nursing."

"Approach: Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN.
Discipline: Physician."

"Approach: Encourage ambulation to level of tolerance
Discipline: C.N.A.'s, Nursing."

"Approach: Ensure access to services.
Discipline: Social Services."

2. Patient B (admitted 12/22/14, MTP Review 1/20/15)

"Approach: Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN.
Discipline: Nursing, Physician, Psychiatrist/Psychologist."

"Approach: Provide 1:1 time along with group and individual activities.
Discipline: Occupational therapist."

"Approach: Ensure access to services.
Discipline: Nursing, Psychiatrist/Psychologist, Social Services."

3. Patient C (admitted 1/19/15, MTP 1/19/15)

"Approach: Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN.
Discipline: Physician."

"Approach: Provide 1:1 time along with group and individual activities.
Discipline: C.N.A., Nursing."

"Approach: Occupational therapy groups reviewed and identified for patient use.
Discipline: Occupational therapist."

"Approach: Ensure access to services.
Discipline: Social Services."

"Approach: Offer fluids to prevent dehydration.
Discipline: C.N.A.'s, Nursing."

4. Patient D (admitted 1/20/15, MTP: 1/20/15)

"Approach: Occupational therapy groups reviewed and identified for patient use.
Discipline: Activities, Occupational therapist."

"Approach: Provide 1:1 time along with group and individual activities.
Discipline: C.N.A.'s, Nursing, Occupational therapist."

"Approach: Social Worker will provide resources and referrals to outpatient placements and may arrange for visits with placement.
Discipline: C.N.A.'s

"Approach: Ensure access to services.
Discipline: Nursing, Psychiatrist/Psychologist, Social Services."

5. Patient E (admitted 1/22/15; MTP 1/22/15)

"Approach: Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN.
Discipline: Nursing, Physician, Psychiatrist/Psychologist, Social Services."

"Approach: Provide 1:1 time along with group and individual activities.
Discipline: Occupational therapist."

"Approach: Ensure access to services.
Discipline: Nursing, Psychiatrist/Psychologist, Social Services."

"Approach: Offer daily session 1:1 or with tx team to review s/sx [signs and symptoms] of [patient name]"s progress with symptoms, and tx [treatment] options for the same.
Discipline: NP, Nursing, Physician, Psychiatrist/Psychologist, Social Services."

6. Patient F (admitted 1/22/15, MTP 1/22/15)

"Approach: Provide 1:1 time along with group and individual activities.
Discipline: Occupational therapist."

"Approach: Evaluate for high risk psychosocial issues requiring a change in treatment planning or interventions in the community."

"Approach: Ensure access to services.
Discipline: Nursing, Psychiatrist/Psychologist, Social Services."

7. Patient G (admitted 1/22/15, MTP 1/22/15)

"Approach: Provide 1:1 time along with group and individual activities.
Discipline: Nursing, Occupational therapist."

"Approach: Occupational therapy groups reviewed and identified for patient use.
Discipline: Activities, Occupational therapist."

"Approach: Complete partner conflict worksheet.
Discipline: C.N.A.'s"

"Approach: Ensure access to services.
Discipline: Nursing, Psychiatrist/Psychologist, Social Services."

8. Patient H (admitted 1/18/15, MTP 1/18/15)

"Approach: As appropriate nursing staff will encourage group attendance or offer individual group time.
Discipline: C.N.A.'s"

"Approach: Assess for possible side effects of the medications and the need to adjust doses, or change medications as needed. Provide medication teaching in collaboration with RN.
Discipline: Physician."

"Approach: Offer daily session 1:1 or with tx team to review s/sx [signs and symptoms] of [patient name]"s progress with symptoms, and tx [treatment] options for the same.
Discipline: Physician."

"Approach: Provide 1:1 time along with group and individual activities.
Discipline: Occupational therapist."

B. Staff Interviews

1. The Director of Nursing stated in an interview on 1/27/15 at 11:20 a.m., "The discipline is identified as the responsible party for particular treatment approaches. I don't know how we would cite an individual person to be responsible."

2. The Treatment Director stated in an interview on 1/27/15 at 2:00 p.m., "The treatment plan identifies which department is responsible for treatment, not which individual is responsible."

3. RNII agreed in an interview on 1/27/15 at approximately 3:50 p.m., that the MTPs needed to include the names of staff responsible for the treatment interventions.


C. Policy Review

1. Facility Policy titled "Treatment Plans" effective 5/3/05 and updated 8/25/14. This policy does not require the primary responsible staff name and discipline to be listed with interventions in the Master Treatment Plans.

Based on observations, patient and staff interviews, record reviews, and document reviews, the facility failed to:

I. Ensure that sufficient active therapeutic efforts were provided to 6 of 8 patients (A, B, C, D, F and G) in the active sample. Specifically, Patients C, F, and G refused to attend treatment groups and were observed to be in their rooms alone at the times when therapeutic groups were being offered; and Patients A, B, and D reported a lack of treatment on weekends and evenings. The patients' reports were validated with staff interviews, a review of the Progress Notes, and a treatment schedule review. Failure to provide sufficient therapeutic treatment denies the patient the care required to ensure his/her optimal improvement and can lead to an extended hospital stay.

II. Ensure that a comprehensive face-to-face evaluation of the patient's status within one hour of initiation of a seclusion and/or restraint (S&R) procedure was documented for three (3) of threee (3) discharged patients (R1, R2, R3) whose records were reviewed for recent restraint episodes. Review of Seclusion/Restraint forms and progress notes during the first hour after S&R revealed that notes did not document a comprehensive assessment that included: an evaluation of the patient's medical condition with a complete review of systems; a behavioral assessment; a review of medications and recent laboratory results if available; and the need to continue or discontinue the seclusion and/or restraint procedure. The lack of a complete evaluation of a patient during the first hour of seclusion or restraint may potentially result in failure to identify adverse physical and mental effects of a seclusion or restraint procedure. Furthermore, the facility failed to document fully that less restrictive measures were used to assist the patient before placing him/her in 4-point or 5-point restraints. Failure to systematically treat the patient in the least restrictive manner violates patients' dignity and respect.

III. Ensure that the physician's orders were followed for Patient B, after the patient received two electroconvulsive treatments (ECT). The patient's vital signs, neurological status, and oxygen saturation were not monitored with the frequency at which they were ordered. Failure to monitor the patient after an ECT places the patient at a potential risk for medical complications that could occur following this medical procedure.

Findings include:

I. Failure to provide adequate active treatment

A. Observations

1. On 1/26/15, surveyors entered the unit at 10:30 a.m. and observed Patients A, B, and D sitting at the dayroom table. When asked about their schedule that day, Patient D stated, "We are just waiting for lunch now. Nothing will happen until group this afternoon." Patients C, F and G were in bed at this same time.

2. On 1/26/15, Patient D was observed watching cartoons on television from 2:30 p.m. until 4:30 p.m.

B. Patient Interviews

1. Patient A stated in an interview on 1/26/15 at 11:00 a.m., "The weekends are boring. We just sat around and watched T.V. I colored in a coloring book. There are no doctor visits on weekends. Doctors don't see anyone on weekends unless they are new." Furthermore, s/he stated that a "typical" hospital day for her/him is "going to stretch, doing a craft, talking to staff and watching TV."

2. Patient B stated in an interview on 1/26/15 at 10:30 a.m., "I do get bored here. Weekends are the longest. Hopefully, we get visitors on the weekend. There are no doctor visits on the weekend and the OT staff is not here on the weekends. In the evening, we watch a movie or TV. We have played Apples-to-Apples and Scrabble. The TV is on all day here."

3. Patient C stated in an interview on 1/26/15 at 11:30 a.m., "The days are long here. I get bored. I read or do work assignment sheets. I don't go to groups. On the weekend, we found a way to occupy our time. We played cards and I read. In the evening, we watch TV, play cards, or read. There are no groups in the evening."

4. Patient D stated in an interview on 1/26/15 at noon, "It's nice here in the hospital: I get to sit back and watch TV. There are no groups on the weekend. Weekends are slow. I see my doctor on weekdays, but not on the weekend."

C. Staff Interviews

1. RN1 stated in an interview on 1/26/15 at 1:05 p.m., "[Patient C's name] has not been engaged in anything much. If patients don't go to groups, they can do their treatment task papers that the doctor gives them. Or they can play cards or Banana Grams."

2. OT1 stated in an interview 1/26/15 at 1:00 p.m., "[Patient C's name] was not in group today. S/he stayed in bed."

3. RN3 stated in an interview on 1/26/15 at 2:00 p.m., "There is nobody here on weekends to do formal, structured groups."

4. The Client Services Manager stated in an interview on 1/27/15 at 1:00 p.m., "The social workers work Monday through Friday. Generally, the hospital does not discharge patients on Saturday or Sunday. Social workers don't run groups or do much direct treatment other than discharge planning and utilization review."

D. Patient Record Review:

1. Patient C: Admitted on 1/19/15 with psychiatric diagnoses of alcohol dependence and anxiety state NOS. The "Problem Evaluation Notes Report" read:

"1/20/15 declined all groups offered, wants to get some explainations (sic) from the Dr.
1/22/15 declined all groups again today, many excuses to not attend.
1/23/15 did not attend
1/23/15 Pt. did not attend morning OT groups.
1/26/15 refused groups this am"

Patient C's Progress Notes read:

"1/20/15 11:05 Pt ref [refused] group, and has been laying (sic) in his/her bed awake... When staff had him/her come out to point where the RN office was, s/he seen (sic) all the peers and staff in the day room and returned to his/her room right away."
"1/20/15 21:39 Pt spent most of shift in room, except for dinner."
"1/21/15 16:09 Pt spending x [time] watching tv and phone calls."
"1/22/15 10:39 [Patient name] has spent most of the morning is his/her room."
"1/23/15 20:45 Appears pt @ this time not to (sic) interested about his/her tx [treatment] right now."

Furthermore, though Patient C's record clearly identifies the contrary, the Weekly Summary in the Progress Notes written by RN1 on 1/26/15 9:22 reads: "S/he attends structured, unstructured activities, groups and individual therapies."

2. Patient F admitted on 1/22/15 for schizophrenia, paranoid type. The "Problem Evaluation Notes Report" read:

"1/23/15 did not attend group."
"1/23/15 did not attend morning OT groups."
"1/26/15 Pt. was unavailable for a.m. group."
"1/27/15 Pt did not attend group today."

3. Patient G admitted on 1/22/15 for depression. The "Problem Evaluation Notes Report" read:

"1/23/15: did not attend."
"1/23/15 Pt. did not attend morning OT groups."

E. Document Review

A review of the weekly schedule reflected a dearth of therapeutic activity on weekends and evenings.

The January 26 - February 1, 2015 Weekly Schedule (minus meals) reads:
Monday - Friday
7:30 a.m. Daily Goal Setting
9:15 a.m. Morning Stretch/Mediation
9:30 a.m. OT Experiential Discussion Group
12:30 p.m. outside/recreation
1:00 p.m. Art with OT
5:30 Psych tech group

Saturday and Sunday
7:30 a.m. Daily goal setting
9:15 a.m. Morning Stretch/Mediation
12:30 p.m. outside/recreation
5:30 Psych tech group

No structure activities are offered after 5:30 p.m. on any day of the week. No Occupational Therapy groups are offered on weekends.

II. Failure to document one hour face-to-face assessments after initiation of S&R and to document less restrictive interventions used prior to restraint.

Findings include:

A. Record Review

1. Patient R1 was placed in a 5-point restraint on 11/25/14 at 2205 [10:05 p.m] for "assaultive and destructive" behavior. Documentation of "Events leading up to and reasons for restraint/seclusion," reads: "[Patient name] was placed in 5-point restraints at this time. Pt. was refusing to leave the police squad. Police had to pull pt. out. Pt needed much physical assist (sic) to be brought on the unit. Pt repeated I'm not going in there several times. Once on the unit pt refused to comply and attempted to stop officers from moving him into the exam room. At this point a stat was called and pt was placed in restraints." There is no documentation of the staff using less restrictive seclusion measures before placing the patient in restraints. There is no documentation of a comprehensive assessment of that patient that included a review of systems, a review of medications, a review of the patient's medical condition, or a statement of why the patient was placed in restraints prior to using a less restrictive treatment measure. The only documentation of an assessment was that of the RN checking the patient's circulation and offering verbal reassurance.

2. Patient R2 was placed in a 5-point restraint on 8/17/14 at 1323 [11:23 p.m.] for "constant threatening and verbally abusive" behavior. Documentation of "Events leading up to and reasons for restraint/seclusion," reads: "[Patient ' s name] continued to be very delusional and agitated. He re-seated on a dayroom sofa. Staff sat next to him approximately 10 feet away, when [patient ' s name] stood, walked over to staff, and swung a closed fist forcefully at staff's face....Three staff secured [patient's name] on the dayroom sofa until the nurse could assess and additional staff arrived to assist....[Patient's name] was transported to the restraint room and place in 5-point restraints at the nurse's direction." There is no documentation of the staff using less restrictive seclusion measures before placing the patient in restraints. There is no documentation of a comprehensive assessment of that patient that included a review of systems, a review of medications, a review of the patient's medical condition, or a statement of why the patient was placed in restraints prior to using a less restrictive treatment measure. The only documentation of an assessment was that of the RN checking the patient's circulation.

3. Patient R3 was placed in 4-point restraint on 10/5/14 and 5-point restraint on 10-06-14. Documentation of "Events leading up to and reasons for restraint/seclusion," include the patient being verbally aggressive, demanding, and threatening to staff. Documentation on 10-06-2014 indicates that patient was "yelling out and struggling against restraints." There is no documentation of the staff using less restrictive seclusion measures before placing the patient in restraints. There is no documentation of a comprehensive assessment of that patient that included a review of systems, a review of medications, a review of the patient's medical condition, or a statement of why the patient was placed in restraints prior to using a less restrictive treatment measure. The only documentation of an assessment was that of the RN checking the patient's circulation and being offered verbal reassurance.

B. Staff Interviews:

1. In an interview with the Nursing Manager on 1/28/15 at 8:00 a.m., episodes of seclusion and restraints were reviewed in the electronic medical record. She agreed that the above cited records did not: (a) contain comprehensive one hour face-to-face assessments, nor (b) show evidence that less restrictive measures were used prior to placing the patients in restraints. Furthermore, she reviewed treatment plans of these patients and stated, "The treatment plans have not been updated to reflect the use of seclusions."

2. The Nursing Manager stated in an interview on 1/27/15 at 4:30 p.m., that she considered restraints to be more restrictive than seclusion and that, when a patient is restrained, she would "expect the patient record to document that seclusion was offered before the restraint."

3. The Treatment Director stated in an interview on 1/27/15 at 2:00 p.m. that he agreed, "Restraints are more restrictive than seclusion."

C. Policy Review

1. Norwood Health Center Policy entitled "Seclusion/Restraints" (Date 5/7/120 states: "The form of the seclusion/restraint implemented will be no more restrictive than the therapeutic management of the presenting behavior demands and will be used for the shortest time possible. The inadequacy of the least restrictive interventions, and the patient response to same, will be documented as evidence of the need for restrictive measures."

III. Post- ECT monitoring

Findings include:

A. Record Review

Patient B was admitted 12/22/14 for major depressive disorder and suicidal ideations. On 1/20/15 and 1/23/15, s/he received his/her first two electroconvulsive therapy treatments. Physician orders written the day before each ECT treatment included the following order: "Vital signs q 2 hours with O2 sat [oxygen saturation] and neuro checks." No stop time was noted for the q 2 hours assessments. A review of the progress notes reflected that on 1/20/15, the patient returned from ECT and had vital signs, neurological status, and oxygen saturation recorded at 10:15 a.m., 12:15 p.m., and 3:15 p.m. On 1/23/15, the patient returned from ECT and had vital signs, neurological status, and oxygen saturation recorded at 10:45 a.m. and 1:00 p.m. No additional assessments, which would indicate that the nursing staff followed the physician's order, were recorded for either day of the ECT treatment.

B. Staff Interviews

1. RN1 stated in an interview on 1/27/`5 at 7:30 a.m. that the nursing staff "interpreted the doctor's order" to be that vital signs, oxygen saturations, and neurological checks should be done until 4:00 p.m. on the day of ECT.

2. The Nurse Manager stated in an interview on 1/27/15 at 9:00 a.m. that the doctor's order meant that vital signs, oxygen saturations, and neurological checks should be done q 2 hours twice and then only routine vital signs needed to be done.

3. The Treatment Director stated in an interview on 1/27/15 at 2:00 p.m. that the order is "open-ended" and that it needed to be revised. He further commented that the order was complicated because the patient left "on-pass" soon after ECT treatment and was not present in the hospital for any type of assessment to be done.

C. Policy Review

Though several attempts were made by the Director of Nursing, no policy regarding nursing protocol following ECT could be located and given to the surveyors.

Based on record review, staff interview, and policy review, the facility failed to provide a discharge summary for two (2) of five (5) reviewed discharge records (D1, D2) that included a recapitulation of the patient's hospitalization. This failure results in no information being made available to out-patient therapists or a record of what interventions, while hospitalized, were or were not effective for two (2) of five (5) sampled discharge records.

Findings include:

A. Record Review

1. Five (5) discharge records that had been closed for more than 30 days were randomly selected for review. Two (2) of the five (5) records (D1, D2) had no discharge summary. Record D1 has a discharge date of 12/11/14 and Record D2 has a discharge date of 12/16/14.

B. Staff Interview

1. The Health Information Manager stated in an interview on 1/26/15 at 4:30 p.m. that records D1 and D2 had no written discharge summaries. She stated that both had been dictated but not transcribed.

C. Policy Review

1. Hospital Policy: Medical Records Standards and Management (6/2/14) states: "A discharge summary, which contains the outcome of hospitalization, disposition of care, provisions for follow-up care and discharge diagnoses, will be completed by the physician within 30 days of discharge."

Based on record review, staff interview, and policy review, the facility failed to provide a discharge summary for two (2) of five (5) reviewed discharge records (D1, D2) that made recommendations for appropriate services concerning follow-up or aftercare. This failure results in no direction for follow-up care or what might benefit patient post hospitalization for two (2) of five (5) sample discharge records.

Findings include:

A. Record Review
1. Five discharge records that had been closed for more than 30 days were randomly selected for review. Two (2) of the five (5) records (D1, D2) had no discharge summary. Record D1 has a discharge date of 12/11/14 and Record D2 has a discharge date of 12/16/14.

B. Staff Interview

1. The Health Information Manager stated in an interview on 1/26/15 at 4:30 p.m. that records D1 and D2 had no written discharge summaries. She stated that both had been dictated but not transcribed.

C. Policy Review

1. Hospital Policy: Medical Records Standards and Management (6/2/14) states: "A discharge summary, which contains the outcome of hospitalization, disposition of care, provisions for follow-up care and discharge diagnoses, will be completed by the physician within 30 days of discharge."

Based on record review, staff interview, and policy review, the facility failed to provide a discharge summary for two (2) of five (5) reviewed discharge records (D1, D2) that included a summary of the patient's condition upon discharge. This failure results in no information about the patient's clinical status that would support the decision that discharge was appropriate at that time for two (2) of five (5) sampled discharge records.

Findings include:

A. Record Review

1. Five discharge records that had been closed for more than 30 days were randomly selected for review. Two of the five records (D1, D2) had no discharge summary. Record D1 has a discharge date of 12/11/14 and Record D2 has a discharge date of 12/16/14.

B. Staff Interview

1. The Health Information Manager stated in an interview on 1/26/15 at 4:30 p.m. that records D1 and D2 had no written discharge summaries. She stated that both had been dictated but not transcribed.

C. Policy Review

1. Hospital Policy: Medical Records Standards and Management (6/2/14) states: "A discharge summary, which contains the outcome of hospitalization, disposition of care, provisions for follow-up care and discharge diagnoses, will be completed by the physician within 30 days of discharge."

Based on interviews, record reviews, and document reviews, the Medical Director failed to:

I. Ensure that social service assessments included conclusions and recommendations that describe anticipated social work roles in treatment and discharge planning for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H). This deficiency results in a lack of professional social work treatment services and lack of input to the treatment team. (Refer to B108)

II. Ensure that Master Treatment Plans (MTPs) were comprehensive, individualized, and behaviorally descriptive with all necessary components for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H). Specifically, the MTPs did not include the following: (1) a substantiated diagnosis (Refer to B120); (2) specific individualized active treatment interventions (Refer to B122); and (3) the name of the staff person responsible for implementing the treatment (Refer to B123). Failure to develop individualized MTPs with all the necessary components impedes the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's active treatment needs not being met.

III. Ensure that sufficient active treatment measures and care were provided to six (6) of eight (8) active sample patients (A, B, C, D, F and G) in order to move the patient to a higher level of functioning. Failure to provide a treatment setting that provides sufficient active treatment denies the patient the care required to ensure his/her optimal improvement. (Refer to B125-I)

IV. Ensure that seclusion and restraint measures were used as a least restrictive intervention in active treatment and that documentation of seclusion and restraint included a comprehensive face-to-face evaluation of the patient's status within one hour of initiation of a seclusion and/or restraint (S&R) procedure. (Refer to B125-II)

V. Ensure that the facility provided a discharge summary that included a recapitulation of the patient's hospitalization, made recommendations for appropriate services concerning follow-up or aftercare, and included a summary of the patient's condition upon discharge. (Refer to B133, B134, and B135)

Based on document review and interview, the facility failed to have a Director of Nursing with a Master's Degree in Psychiatric or Mental Health Nursing, psychiatric nursing experience, and/or documented evidence of consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing. This failure resulted in the facility having a nurse executive without the necessary skills for providing effective, evidenced based care for patients with psychiatric disorders.

Findings include:

A. Document review

1. Review of the Director of Nursing resume in the employee's Human Resource file provided by the DON, revealed that the DON (hired at the facility in April 2011) had a diploma degree in nursing, and clinical experience as an RN on an inpatient psychiatric unit between 4-5 years ("1987-1991 or 1992.")

2. The resume of the Director of Nursing states that she worked in Pediatric Intensive Care in 2008, Oral Surgery from 2003- 2008, and Home Care from 1990-2000. The only mental health experience cited in the DON ' s resume was from "1987-1991 or 1992."

3. The "Educational Tracking" document for the DON provided by the DON noted no continuing education in psychiatric nursing.

B. Interview

1. In an interview on 1/27/15 at approximately 1:05 p.m., the Director of Nursing stated that she has a Diploma in nursing. When asked if she consults with a Masters prepared nurse, she stated does not.

Based on record review and interview, the Director of Nursing failed to assure that Registered Nurses develop and implement individualized psychiatric interventions for eight (8) of eight (8) active sample patients (A, B, C, D, E, F, G and H). The treatment plans listed nursing approach (interventions) that were routine required tasks, generic discipline functions instead of individualized approach (interventions) specific to the patient's psychiatric needs. This failure resulted in lack of active, individualized modalities that provides a basis for purposeful goal directed treatment. (Refer to B122 and B123)

Findings include:

A. Record Review

The treatment plans for eight (8) of eight (8) active records (A, B, C, D, E, F, G and H) listed nursing approach (interventions) that were routine required tasks, generic discipline functions instead of individualized approach (interventions) specific to the patient's psychiatric needs.

B. Interview

In an interview on 1/27/15 at approximately 1:05 p.m., after reviewing and discussing the treatment plans for the sample patients, the DON acknowledged that the nursing approach (interventions) on the patients' MTP were assigned to various disciplines rather than to any one person(s).