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Based on record review and patient and staff interviews, the hospital failed to ensure prompt resolution of a grievance and give results to 1 of 1 applicable patient (#16), out of a total sample of 31.

Findings include:

Patient #16 was admitted to the hospital on 2/9/12 with diagnoses which included suicidality, migraines and chronic pain.

During interview on 3/14/12 at 3:30 P.M., Patient #16 said that in February, the patient reported to the Human Rights Officer issues regarding having to wait 16 hours for someone to clean up patient's bedside when patient vomited and concerns with a nurse who patient felt was not treating the patient with dignity and respect. Patient #16 stated that these concerns were not resolved, and no staff person reported back to this patient with any feedback regarding the reported concerns.

Review of the patient's clinical record reflected the following nurses' notes:

2/26/12 at 10:40 P.M., "6 P.M. complained of distress, nausea, without vomiting, reports vomited in toilet, none observed.

2/27/12 at 1:20 P.M, "reporting migraines, nausea and vomiting, "brain leak," and need for IV fluids to treat migraine".

2/27/12 at 9:40 P.M., "patient isolated in bedroom reporting ,"feeling afraid of select staff" and not wanting them to see him/her. Patient claims he always picks on me when I am on the floor so I just stay in my room so he/she doesn't bother me."

Review of the complaint log on 3/15/12 reflected an incident regarding Patient #16 with a documented interview of Patient #16 with the Human Rights Officer. The interview was on 2/28/12 at 3:30 P.M. The investigation confirmed that Patient #16 reported that it took staff 16 hours to clean the patient's room and that because of the lack of attention by staff, the patient called 911 three times that evening.

During interview with the Human Rights Officer on 3/15/12 at 2:20 P.M., the Human Rights Officer said he was aware of the reported incident regarding the patient's concern of lack of care for 16 hours and was also aware that this patient had reported a concern of the way a nurse treated this patient. The Human Rights Officer said that he did not fully investigate the lack of care for 16 hours, and he referred the concern regarding the nurse to the nursing department. He never went back to the patient to help resolve the patient's issues.

Review of the hospital's policy entitled Investigation & Reporting Responsibilities, Policy #COM-01 stated that at a minimum, any fact-finding activity relative to a complaint must include interviews with the complainant; the patient; each of the individuals complained of;...then a written decision to the parties within ten days containing findings of fact and conclusions and any action to be taken will take place.

This did not occur.

Based on observation and staff interview, the hospital failed to ensure privacy for two of 31 sampled patients (#4 and #10) and one Non-Sampled Patient (NS#A).

Findings include:

1. For Patient #4, the hospital failed to provide privacy when personal issues were being discussed.

On 3/14/12 at 9:50 A.M. on the South Unit, Patient #4 was seated in front of the nurses' station when approached by Physician #1. Two surveyors were seated behind the nurses' station and three patients were adjacent and within ear shot of the patient and Physician #1. Without ensuring privacy for the resident, Physician #1 was heard to discuss this patient's treatment plan and need for medications. At no time did the Physician attempt to redirect the patient to a private place to talk. At no time did staff who who were also at the nurses' station, attempt to intervene on behalf of patient privacy.

On the same date at 10:05 A.M. on the South Unit, Patient #4 was again approached by Medication Nurse #1 to discuss the need for medications in front of the nurses' station. The two surveyors were still seated behind the nurses' station and patients were milling around this common area within ear shot of the discussion which was being held. There was no redirection on the part of Medication Nurse #1 or other staff members who were also at the Nurses' Station.

The hospital failed to ensure that this resident was provided with privacy during discussion of personal issues.

2. For Patient #10, the Hospital failed to provide privacy when confidential issues were being discussed.

On 3/15/12 at 9:20 A.M. on the South Unit, Patient #10 was observed seated in the common area in front of the nurses' station. Two surveyors were seated behind the nurses' station and four patients were adjacent and within ear shot of the patient and Nurse Practitioner #1. Without ensuring privacy for the patient, Nurse Practitioner #1 was heard to discuss this patient's bowel movements and frequency. At no time did the Nurse Practitioner #1 attempt to redirect the patient to a private place to talk. At no time did staff who who were also at the nurses' station, attempt to intervene on behalf of patient privacy.

The hospital failed to ensure that this patient was provided with privacy during discussion of personal issues.



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3. For Patient NS #A, the hospital failed to provide privacy when personal issues were being discussed.

a. Observation of the common area across from the South Unit nursing station, on 3/13/12 between 2:45 P.M. and 3:05 P.M., revealed Physician #1 having a conversation with Patient NS#A. The conversation between Physician #1 and Patient NS#A was loud enough and easily overheard by two patients seated in the same common area in front of the nursing station and two surveyors seated behind the nursing station. Physician #1 asked Patient NS#A about his/her past alcohol consumption. Physician #1 was heard discussing Patient NS#A's medications with Patient NS#A.

b. Observation of the common area across from the South Unit nursing station, on 3/14/12 between 9:50 A.M. and 10:10 A.M., revealed Physician #1 was in conversation with Patient NS#A. The conversation between Physician #1 and Patient NS#A was easily overheard by three patients seated across from the nursing station and two surveyors seated behind the nursing station. Again, Physician #1 was heard discussing Patient NS#A's medications with Patient NS#A.

Based on record review and staff interview, the hospital failed to develop, review, and revise the care plan for one restrained patient (#1) in a total sample of 31 patients.

Findings include:

For Patient #1, the hospital failed to update the care plan to include the use of restraints.

Patient #1 was admitted to the facility on 2/21/12, with a diagnosis of dementia with psychosis.

On 3/6/12 at 12:30 P.M., Patient #1 was restrained in a physical hold for 3 minutes after Patient #1 threw a chair at staff and began swinging his/her fists at staff. The Patient was also observed trying to break the glass mirror in the bathroom.

Further record review indicated that the patient's care plan was not updated to include the use of restraints.

On 3/14/12 at 10:55 A.M., Unit Manager #2 said the patient's care plan was not updated to include the use of restraints.

Based on record review and staff interview, the hospital failed to ensure that physical restraints were implemented only when ordered by the physician for 1 restrained (Patient #1) sampled patient in a total sample of 31.

Findings include:

For Patient #1, the hospital failed to ensure a physician's order was obtained when a physical restraint was implemented.

Patient #1 was admitted to the facility on 2/21/12, with a diagnosis of dementia with psychosis.

Record review on 3/13/12 indicated that on 3/6/12 at 12:30 P.M., Patient #1 was restrained in a physical hold for 3 minutes after Patient #1 threw a chair at staff and began swinging his/her fists at staff. Patient #1 was also observed trying to break the glass mirror in the bathroom. Patient #1 was restrained in a physical hold for 3 minutes while a chemical restraint was administered. At 12:33 P.M., Patient #1 was released when he/she was calm and sat on the edge of the bed.

Review of the 3/12 physician's orders indicated that there was no physician's order on 3/6/12 for a physical restraint. Patient #1 had an order for a chemical restraint for assaultive behavior.

Review of the hospital's Restraint/Seclusion Policy and Procedure dated 5/20/11, indicated that a physician's order must be obtained and must state the type of restraint, the maximum amount of time a patient will be in restraints, and the reason for the restraint. In addition, according to the policy, Emergency Restraint and Seclusion Forms are completed in triplicate during the emergency occurrence, and one copy will be maintained in the patient's medical record.

Review of the Emergency Restraint and Seclusion Form, dated 3/6/12, indicated that the emergency interventions used were a physical restraint, "only to administer medications" and a chemical restraint. The patient's physician saw the patient at 12:33 P.M., and the physician did document his/her evaluation of the patient.

On 3/13/12 at 10:55 A.M., Unit Manager (UM) #2 said Patient #1 did not have a physician's order for the physical hold on 3/6/12. UM #2 said she was not aware that a physical hold was considered a physical restraint because the physical hold was implemented while administering a chemical restraint.

Based on review of the Quality Assurance/Performance Improvement (QAPI) Plan and minutes from 10/2011 through 2/2012, the Hospital failed to track and analyze patient grievances and infection control surveillance data and failed to review nursing performance improvement activities, as a process of care and hospital operations.

Findings include:

1. Review of the Performance Improvement Program provided by the Hospital on 3/16/12, indicated the purpose of the program is to provide a system to guide continuous, systematic, planned hospital-wide activities to improve hospital performance, patient outcomes, as well as patient satisfaction. This will be accomplished through a process that focuses on patient focused functions such as ethics, rights and responsibilities, provisions of care, treatment and services, medication management, infection control, surveillance, and prevention and patient safety. In order to guide process improvement and data collection, the Hospital utilizes a systematic problem solving method based on finding a process to improve; organizing a team that knows the process; clarifying current knowledge of the process; understanding causes of the process variation and selecting the process improvement. This is followed by plan improvement and data collection, analysis, checking data for process improvement and acting to hold and continue improvement. The Performance Improvement Committee coordinates and oversees the quality improvement program.

2. Review of the QAPI minutes from 10/2011 through 2/2012, indicated the committee did not receive any data for review on patient grievances. During survey, nine patient complaints were reviewed that occurred in 2011 and early 2012. The nature of these complaints varied but included sexual assault as well as patient rights violations.

Review of the Human Rights committee minutes indicated on 12/11/11, that in summary for 2011, patient grievances consisted of complaints about staff behavior, room-mate issues, food issues, legal problems, and Health Insurance Portability and Accountability Act (HIPAA) issues. There were no corrective actions identified.

During an interview, on 3/19/12 at 9:00 A.M., the Human Rights Officer said that he had not reported any grievance activity to the QAPI committee or discussed it at QAPI meetings. The Human Rights Officer said there was no performance improvement plans currently for patient grievances but all grievances had been addressed.

3. Review of the QAPI minutes also indicated that the nursing department had not reported to the committee on any nursing activities, since 8/2011.

Review of the 8/26/11 QAPI minutes indicated nursing was active in tracking and trending falls throughout the hospital and had an ongoing performance improvement project to decrease falls in place. On 9/28/11, nursing stopped using the "red sock" protocols after identifying they increased fall risk and put protocols into place to have orders for assistive devices for ambulation with a plan to continue to monitor.

There was no further reporting of falls tracking from nursing to the QAPI committee. On the 2/2012 QAPI agenda, nursing was scheduled to report data on fall analysis. Minutes indicated all nursing reports were tabled to the April 2012 meeting. Review of incident reports indicated there was an average of 16 falls a month between October 2011 and February 2012. There was an average of 3 falls with injury each month.

4. Review of the infection logs from January 2011 through January 2012 indicated a high incidence of urinary tract infections (UTI) each month. No trending or analysis of the infections was done. By surveyor calculations, UTIs were 56% of all hospital infections and 1/3 to 1/2 of all UTIs each month were hospital acquired. During interview, on 3/14/12 at approximately 2:00 P.M., the Infection Control Nurse (ICN) said this was accurate.

Review of Infection Control (IC) data reports to the Quality Assurance Performance Improvement Committee (QAPI) indicated that on 11/30/11, the ICN reported the total infection rates for the months of April 2011 through October 2011 but failed to break down the rates into each infection type. The ICN reported that UTIs were the most common infection, but did not give any statistical information to the QAPI committee or recommend any performance improvement goals. No performance improvement plan was recommended or implemented.

Based on review of four of four credentialing files of registered nurses practicing in expanded roles (Clinical Nurse Specialist (CNS) #1, Nurse Practitioners (NP) #2, #3 and #4, the Director of Nursing Services (DON) of the Hospital failed to perform a formal review and approve the guidelines under which each NP proposed to practice in the Hospital as required by Massachusetts Board Registration in Nursing regulations at CMR 244. 4.22.4 (a).

Findings include:

1. According to the Massachusetts Board of Registration in Nursing regulations at CMR 244. 4.22.4 (a), Development, Approval, and Review of Guidelines for Nurse Midwifes, Nurse Practitioners and Nurse Anesthetists, a nurse practicing in an institution may not practice in an expanded role until the governing body, including the medical staff and nursing administrative staff of the institution, formally reviews and approves the guidelines under which ( the NP) proposes to practice.

2. Review of the credentialing files for CNS #1, NP#2, NP#3, and NP#4, indicated no evidence that the nursing administrative staff (DON) approved of the requested proposed practice of any of the nurses. For example:

a. CNS #1 requested admitting privileges and to provide primary care as well as general adult psychiatric care. The request for privileges was approved by signature by the Medical Director on 2/9/11 and by the Board of Directors on 2/10/11. There was no evidence of review and approval by the DON (nursing administration). Review of the CNS credentials indicated the CNS #1 was not an adult nurse practitioner but only a clinical nurse specialist who was licensed to provided psychiatric care. The Medical Director (MD) said on interview, on 3/9/12 at approximately 11:00 A.M., that CNS#1 was not eligible to admit and provide primary care by training and should not have been signed off as granted those privileges.

b. NP #2 requested privileges as an associate medical staff to admit and provide primary care. The request was approved by the MD on 11/24/10 and the Governing Body (GB) on 12/6/10. There was no evidence that the DON (nursing administrative staff) reviewed and approved the requested proposed practice.

c. NP#3 requested privileges as an associate medical staff to admit and provide primary and psychiatric care to patients. The MD approved the request on 12/7/11 and the GB approved it on 12/9/11. There was no evidence that the DON (nursing administrative staff) reviewed and approved the requested proposed practice.

d. NP #4 requested reappointment as an associate staff member to practice internal medicine which was approved by the MD on 12/7/11 and approved by the GB on 1/13/12. There was no evidence that the DON (nursing administrative staff) reviewed and approved the requested proposed practice.

3. On 3/12/12 at approximately 10:00 A.M. during interview with the DON, the DON said that she does not review or approve the requests for practice for any of the nurses practicing in expanded role. After review of the Board of Registration in Nursing requirements with the surveyor, the DON said that she clearly needed to review advanced practice nurses during the credentialing process.

Based on record review and interview, the Hospital failed to accurately assess three (#25, #28 and #30) of 31 patients during the admission nursing assessment. Findings include:

1. For Patient #30, admitted with diagnosis of developmental delay and bipolar disorder, the nursing admission assessment documented the patient's bladder continence status as "within normal limits."

Record review of referral information received from the emergency room indicated the patient had a three week decline in mental status at the group home where the patient resided which included the onset of urinary incontinence and frequent bedwetting at night.

On 3/14/12 at 8:30 A.M., during interview, the unit manager said the assessment was not accurate as the patient is incontinent.

2. Patient #28, was admitted with Bipolar disorder and one month status post cerebral vascular accident (CVA) with left sided weakness.

Observation of the patient on 3/14/12 from 8:30 A.M. to 9:00 A.M. and 3/15/12 from 3:30 p.m. until 4:00 P.M., indicated the patient wore a left leg foot to knee splint and a left wrist splint. The patient also had a left arm paresis and was unable to move the arm, hand or fingers independently. The patient was observed to walk independently with a cane and the left leg splint.

On 3/15/12 at 3:45 P.M., the patient said during interview, that he/she can't see anything but a blur out of the left eye since the CVA. The patient also said, " I can't get anyone to help in the bathroom" with clothing. The patient said that due to left arm weakness, the patient is unable to manipulate clothing removal and replacement. The patient said he/she is not receiving any physical (PT) or occupational services (OT) but wishes that s/he could get more OT/PT.

The nursing admission assessment documented the patient as having vision "within normal limits" using only a cane for mobility devices, having normal touch sensation, requiring mod assistance with bathing, grooming and upper body dressing and maximum assist with lower body dressing. The falls assessment indicated the patient had a fall in the past year, giving the patient a score of three. Record review indicated the patient fell at home the day of admission (within the past month) and should have been scored a four on the assessment tool.

The assessment failed to address the patient's left sided weakness of the arm and CVA residual deficits such as change in vision, use of splints and failed to assess falls history accurately.


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3. Patient # 25, was admitted with substance abuse, petit mal seizures and hepatitis C.

The admission nursing assessment failed to document that the Patient had hepatitis C on the nutrition section of the assessment. This would trigger a nutritional consult for the Patient.

During interview on 3/14/12 at 12:15 P.M., Unit Manager (UM) #1 said that the hepatitis C should have been documented as a liver disease on the nursing assessment form. This would have resulted in a nutritional assessment being conducted as per Hospital policy.

Based on observation, record review, patient and staff interviews, the hospital failed to develop, review, revise and/or implement the care plans for 15 patients [#1, #3, #4, #14, #16, #19, #20, #21, #23, #24, #25, #26, #27, #28, and #30] in a total sample of 31.

Findings included:

1. For Patient #4, the hospital failed to develop and implement a nursing care plan to address urinary track infection, (UTI), diabetes, activities of daily living (ADL's) requiring assistance and pain.

Record review on 3/14/12 of the nursing admission assessment dated 3/9/12 noted the patient is on an antibiotic for UTI, has diabetes, complained of back pain and needed moderate assistance with bathing, transfers and ambulation. Review of the Nursing Plan of care lacks interventions to address these issues.

Further record review noted the patient was having hypoglycemic (low blood sugar) episodes and although staff would get physician's order to treat the hypoglycemic episodes, there was no nursing care plan to address diabetes and nursing measures to monitor and prevent complications.

The patient was receiving an antibiotic for a UTI due to Escherichia Coli in the urine. On 3/15/12 at 8:15 A.M. the patient was observed as being incontinent of urine and required a 2 person transfer to get to the bathroom.

The patient was medicated with Tylenol on 3/12/12 for hip pain and on 3/15/12 for back pain.

Under the interdisciplinary Treatment Plan for Axis III diagnosis (Medical Problems): UTI and Pain were noted with the intervention for nursing being "monitor symptoms of acute illness every shift and provide care per nursing care plan or notify MD as needed." There was no nursing care plan to address these issues.

During interview with the unit manager (UM #2) on 3/15/12, said there were no nursing care plans with interventions to address the medical issues regarding pain management, infections, (UTI) and diabetes.

2. For patient #16 the hospital failed to keep a current nursing care plan when this patient developed a sinus and ear infection and severe pain from migraine headaches.

This patient was admitted to the hospital on 2/9/12 for overdosing on Ambien.

Record review on 3/14/12 of the nursing admission assessment dated 2/9/12 noted the patient's understanding why hospitalized was due to an accidental overdose on Ambien to get rid of migraine. The pain assessment reflected the patient is in pain with a severity of 9.5 on a scale of 0-10. The pain is due to back pain and headaches.

During interview with the patient on 3/14/12 at 3:30 P.M., the patient said that towards the end on February, the patient vomited and had severe pain due to migraine headaches and that currently the patient is receiving ear drops for an ear infection and an antibiotic for a sinus infection.

Review of nursing progress notes on 3/15/12 reflected on:

2/10/12, "patient has been somatic today complaining of sinus infection, dry sinus, back pain and issues with meds."...

2/13/12, "patient awake most of shift (11-7) patient complained of pain and migraine"....

2/27/12 1:20 P.M., reporting migraines, nausea and vomiting"...

Review of the nursing plan of care lacked any interventions to address pain management due to migraine headaches and back pain. There was no care plan to address infections regarding sinus and ear infections and to address somatic complaints.

During interview with the unit manager (UM #3) on 3/15/12 said this patient had many somatic complaints and it was difficult to figure out was going on medically with this patient.


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3. For Patient #24, review of the nursing assessment indicated the patient had back pain related to a motor vehicle accident for which the patient took narcotic pain reliever three times a day for management of pain.

Under the interdisciplinary Treatment Plan for Axis III diagnosis (Medical Problems) back pain was identified with the intervention for nursing being "monitor symptoms of acute illness every shift and provide care per nursing care plan or notify MD as needed."

Review of the nursing care plan indicated no plan for pain management.

4. For Patient #26, the Hospital failed to implement the nursing care plan for monitoring the patient's thrombocytopenia.

Patient #26 was admitted with diagnosis of liver disease and thrombocytopenia. On admission the patient was noted to have a large bruise on the ribcage and a low platelet count placing the patient at risk for bleeding.

The nursing care plan for thrombocytopenia had interventions as follows: dietary consult, monitor temperature every four hours, monitor signs and symptoms of bleeding and bruising, check platelets and notify MD of abnormal reports.

Review of progress notes, treatment sheets and all clinical documentation, from 3/4 through 3/13/12, lacked any evidence of monitoring of the patient for bruising or bleeding. On 3/14/12 at 10:00 A.M., when asked by surveyor how the patient was monitored for bleeding and bruising, Unit Manager #1 (UM) said that he asked the patient every day about new bruises. The surveyor asked if the UM documented his discussions with the patient and the UM said "no." Asked if he should have documented his assessment, UM #1 said "yes." Asked why he did not, the UM said that he was more focused on the patient's psychological issues.

Review of the temperature monitoring logs indicated that the patient's temperature was only taken once a day except on 3/8/12 when it was taken three times that day.

The temperature logs were reviewed on 3/14/12 at 10:00 A.M. with UM #1 who said temperatures were not done according to the care plan.

5. For Patient #28, the hospital failed to implement a nursing care plan for management of Activities of daily living (ADLs) and CVA residual effects management and failed to consistently implement the care plan for monitoring of weekly weights.

Patient #28 was admitted on 2/22/12, with Bipolar disorder and status post CVA with left hemiparesis for one month.

On 3/15/12 at 3:45 P.M., the patient said during interview, that the s/he can't see anything but a blur out of the left eye since the CVA. The patient also said "can't get anyone to help in the bathroom" with clothing. The patient said that due to left arm weakness, the patient is unable to manipulate clothing removal and replacement. The patient said s/he is not receiving any physical (PT) or occupational services (OT) but wishes that s/he could get more OT/PT. The patient said an occupational therapy assistant comes to give her a shower every day but not until late in the afternoon. The patient said that s/he is up very early and would like to shower and be ready for the day in the morning.

Record review indicated the patient had an Occupational and Physical therapy evaluation on 2/14/12. The OT did not recommend any services while the patient was hospitalized but stated the patient would need services upon discharge. The OT assessed the patient as requiring moderate assist with lower extremity bathing, set up with grooming, minimal assist with upper extremity dressing and moderate to maximum assist with lower extremity dressing. Toileting activities were not assessed. No plan was recommended for meeting the patient needs while inpatient.

The PT evaluation also recommended home services after discharge. An exercise program was given to the patient to do 2-3 times a day while inpatient and directions for removing the left leg brace every 2-3 hours to relieve pressure and prevent skin breakdown. The PT also recommended ongoing OT treatment to address ADL deficits and left upper extremity and hand range of motion.

Review of the nursing care plan indicated no plan or interventions to meet the patient's ADL needs for bathing, dressing, toileting, no plan for monitoring of the splint use, removal and preventative skin care, and there was no nursing care plan to compensate for the patient's visual deficits.

6. For Patient #27, the Hospital failed to develop nursing care plans for the care and monitoring of abdominal wounds and for the management of Deep Vein Thrombosis (DVT), monitoring and patient education around the use of anticoagulant medication in a high risk patient. The patient was also a diabetic on insulin coverage.

Patient #27 was admitted to the Hospital status post suicide attempt by stabbing, post surgery. Nursing assessment on admission indicated the patient had two abdominal wounds, one surgical with 33 staples and one stab wound.

Review of the nursing care plans indicated there was only a care plan for depression and for knee pain related to arthritis. There were no nursing care plans for the problems of surgical or abdominal wounds, such as monitoring for risk of infection, monitoring of healing, local care, and patient education.

On 3/5/12, progress notes indicate the patient was diagnosed by ultrasound with a left lower leg DVT and was started on anticoagulation with Lovenox. which was then changed to Coumadin. Review of the nursing care plan indicated the plan was not revised to address the new problem of DVT and use of anticoagulation drugs.

7. For Patient #30, the Hospital failed to develop and implement a nursing care plan for incontinence, diabetes and hypertension.

Record review indicated the patient started to have a decline in mental status with a decline in continence three weeks prior to hospital admission. The admission nursing assessment identified the patient as having diabetes and high blood pressure but failed to identify the incontinence, noted in the emergency room referral.

Under the Interdisciplinary Treatment Plan for Axis III diagnosis (Medical Problems) Diabetes was identified with the intervention for nursing being to "monitor symptoms of acute illness every shift and provide care per nursing care plan or notify MD as needed." There was no nursing care plan for diabetic management.

On 3/14/12 at 8:30 A.M., during interview, the UM said that the patient was tested for urinary tract infection and did not have one. The UM said the patient was given adult briefs to use and a shower daily to manage incontinence. The UM said the patient is not on any toileting plan or schedule.

On 3/15/12 at 8:00 A.M., surveyor observed two unused adult briefs in the patient's trash can by the bathroom door. The bed linens were observed to be dry.

Review of the nursing care plan indicated no interventions to manage the patient's new onset of incontinence or to improve the patient's continence. The nursing care plan also lacked any interventions for the management of diabetes and hypertension, as identified in the nursing assessment.

On 3/19/12 at 12:00 P.M., during interview, the Director of Nursing (DON) said that she agreed nursing care plans needed to be more comprehensive of the identified patient nursing and medical needs.


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8. For Patient #1, the hospital failed to implement the medical plan of care which indicated that the patient's vital signs be obtained daily and failed to develop a nursing care plan for a urinary tract infection.

Record review on 3/13/12 indicated that Patient #1 had a physician's order dated 2/22/12, which read, "Vital signs twice a day for 2 days, then daily in the A.M." Review of the 2/12 and 3/12 Medication Administration record (MAR) indicated that vital signs were not obtained at 9:00 A.M.,on 2/28/12, 3/4/12, and 3/11/12 as per medical plan of care.

Further record review indicated that on 3/8/12 the patient was diagnosed with a urinary tract infection and on the same day the patient's physician ordered an antibiotic to be administered twice a day for 10 days. Review of the nursing care plan indicated the hospital failed to develop a care plan to address the patients' urinary tract infection.

On 3/13/12 at 4:00 P.M., UM #2 said the vital signs were not documented as per the medical plan of care. Charge Nurse #3 also said the hospital failed to develop a nursing care plan for a urinary tract infection.

9. For Patient #3, the hospital failed to implement the medical plan of care which indicated the patient's vital signs would be obtained four times a day for three days.

Record review on 3/15/12 indicated the patient had a physician's order dated 3/5/12, which read, " Vital signs four times daily for three days." According to the 3/12 MAR , vital signs were not obtained on 3/7/12 at 1:00 P.M. and at 11:00 P.M. as per the medical plan of care.

On 3/15/12 at 11:00 A.M., UM #2 said the vital signs were not obtained as per the medical plan of care.


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10. For Patient, #14 the hospital failed to develop a nursing care plan for tachycardia, headaches and knee pain.

Patient #14 was admitted in 3/12 with diagnoses including tachycardia, migraines and knee pain secondary to right medial collateral ligament sprain.

Review on 3/14/12 at 11:40 A.M., of the admission physical exam and physician orders indicated that the patient received Propranolol for the treatment of the tachycardia and Tylenol PRN [as needed] for pain. Review of the interdisciplinary treatment plan for medical problems indicated problems with headaches and pain.

During interview on 3/14/12 at 11:50 A.M., Unit Manager (UM) #3, said that the patient was being treated for tachycardia and pain, but these issues were not addressed in the nursing care plan.

11. For Patient #19 the hospital failed to develop a nursing care plan for fibromyalgia, restless leg syndrome and hypertension.

Patient #19 was admitted in 3/12 with diagnoses including Fibromyalgia, restless leg and hypertension.

Review on 3/15/12 at 2:24 P.M., of the interdisciplinary progress notes for 3/11/12, 3/12/12, 3/14/12 and 3/15/12, indicated complaints with leg cramping and pain.

Review of the nursing plan of care failed to identify any goals or approaches to deal with the patients pain.

During interview on 3/15/12 at 2:40 P.M., UM #1 said that the patient was regularly seeking medication for the treatment of pain.

12. For Patient #20, the hospital failed to develop a nursing care plan for migraines, asthma and chronic obstructed pulmonary disease [COPD].

Patient #20 was admitted to the facility in 3/12 with diagnoses including migraines, asthma and COPD.

Review on 3/15/12 at 1:00 P.M., of the medication administration record indicated that the patient required treatment with Fiorinal and Zomig for the treatment of the migraine headaches. Review of the interdisciplinary treatment plan indicated that the patient required treatment for COPD.

Review of the nursing care plan failed to identify any goals or approaches to deal with the patient's migraines or pulmonary problems.


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13. For Patient #21, the hospital failed to develop a nursing care plan for pain, smoking, hypertension and falls.

Patient # 21 was admitted to the hospital with substance abuse, chronic pain, falls, hypertension and depression.

Review of the medical record on 3/14/12, documented that the Patient had withdrawal from opiates, chronic pain, was a fall risk and depression. The Patient was receiving medications for the above conditions.

Under the interdisciplinary Treatment Plan the following areas were identified as needing nursing intervention: major depressive disorder, falls and pain.

Review of the nursing plan of care failed to identify any goals or approaches to deal with the patient's pain, falls or major depression.

14. For Patient #23, the hospital failed to develop a nursing care plan for pain, hypertension, COPD and hepatitis.

Patient #23 was admitted to the hospital with pain, hypertension, COPD, hepatitis and the need to detoxify.

Review of the medical record on 3/15/12, indicated that the Patient had withdrawal from alcohol, pain, hypertension and COPD.

Under the interdisciplinary Treatment Plan the following areas were identified as needing nursing intervention for: self care, detoxification, hepatitis, hypertension, major depressive disorder, falls and pain.

Review of the nursing plan of care failed to identify any goals or approaches to deal with the patients pain, falls, self care and hepatitis/hypertension.

15. For Patient #25, the hospital failed to develop a care plan for self care, pain and petit mal seizures.

Patient # 25, was admitted with substance abuse, petit mal seizures, pain and hepatitis C.

Under the interdisciplinary Treatment Plan, the following areas were identified as needing nursing intervention: self care, detoxification, falls and pain.

Review of the nursing plan of care failed to identify any goals or approaches to deal with the patient's pain, falls and self care.

Based on record review and interview, the Hospital failed to ensure the medical record of two patients (#24 and #26), in a total sample of 31, contained information on the patient's response to medications given on a as needed (PRN) basis.

Findings include:

1. Patient #24 was admitted with a diagnosis of back pain.

Review of the physician' s order indicated the patient could receive Percocet 5/325 milligrams (mgs) one tablet orally three times a day as needed for pain.

Review of the medication administration record (MAR) for March 2012, indicated the patient received 19 doses of the Percocet between 3/8/12 and 3/15/12. However, under the PRN medication notes on the back of the MAR record, only 11 of the 19 doses were documented as to why they were given and only two of the 19 doses given had a response to the medication documented (positive).

2. Patient #26 was admitted with chronic alcohol abuse and withdrawal symptoms.

Review of the physician orders indicated Patient #26 had orders to receive Ativan 1 mg four times a day as needed for symptoms of withdrawal.

Review of the MAR indicated the patient received Ativan on 3/9 at 11:00 A.M., on 3/10 at 9:00 A.M., on 3/12 at 10:50 P.M. and on 3/13/12 at 10:30 P.M. Review of the PRN medication notes on the back of the MAR indicated the Ativan was given for symptoms of withdrawal but failed to describe what those symptoms were. There was no documentation of the patient's response to the medication for any doses administered, as required.

3. During an interview on 3/15/12 at approximately 12:00 P.M., Unit Manager #1 and Medication Nurse #2 both said that all documentation of PRN medication used is located on the back of the MAR record., per hospital policy.

Based on record review and staff interview, the hospital failed to ensure that all medical records were complete and authenticated, consistent with hospital policies and procedures, for 2 sampled patients [#12 and #30] in a total sample of 31 patients. Findings include:

1. For patient #12, the hospital failed to ensure that telephone orders were signed by the physician within 24 hours after the order was received. per hospital policy.

Review of the hospital's policy for physician orders indicated, "A telephone order shall be considered to be in writing if given to a Registered Nurse or a Licensed Practical Nurse. All telephone orders must be timed, dated and signed by physician within 24 hours."

On 3/14/12 at 4:20 P.M., a review of the patient's physician order sheet indicated that on 3/9/12 at 2:00 P.M. and 4:00 P.M. and on 3/12/12 at 4:45 P.M., the hospital received telephone orders for the patient to receive changes in medications. These telephone orders were never authenticated by the physician who ordered the medications. Further review of the physician order sheet indicated that the order sheets were flagged for the physician to sign the orders.

During interview with Nurse #1 on 3/14/12 at 4:40 P.M., Nurse #1 said that the order sheets were flagged so that when the physician comes in he/she would sign the orders.



09115

2. For Patient #30, the hospital failed to ensure that telephone orders were signed by the physician within 24 hours after the order was received.

Review of the physician orders indicated that on 3/12/12 at 2:45 P.M., nursing staff recorded a telephone order for ammonia level, lithium and valproic acid level for Patient #30.

Record review on 3/14/12 at 9:00 A.M. indicated the order had not been authenticated within 24 hours as required by the physician. Further review of the physician order sheet indicated that the order sheets were flagged for the physician to sign the orders.

Based on review of medical records and staff interviews, the hospital failed to ensure that all medical records contained all documentation necessary to monitor the patients' condition for 5 sampled patients [#1, #3, #14, #26 and #27] in a total sample of 31 patients.

Findings include:

1. For Patient #14, the hospital failed to record vital signs, although the physician had ordered that the medication Propranolol be held when the blood pressure and heart rates were below certain parameters.

Patient #14 was admitted to the hospital in 3/12 with diagnoses including tachycardia.

Physician's orders indicated that the patient was to receive 20 mg of Propranolol three times a day. The medication was to be held for a systolic blood pressure below 100 and for a heart rate below 60.

Review on 3/14/12 at 11:40 A.M., of the medication administration record and the vital signs book, indicated that the blood pressure and heart rates were recorded at 9:00 A.M., each morning for administration of the morning medication. The vital signs were not recorded at the two other times a day when Propranolol was administered.

During interview on 3/14/12 at 11:50 A.M., Unit Manager #3 said that when vital signs are normal they are not recorded. The only time that the vital signs are recorded is when they are abnormal.


08949


2. For Patient #1, the hospital failed to document the patient's daily vital signs as per medical plan of care.

Record review on 3/13/12 indicated that Patient #1 had a physician's order dated 2/22/12, which read, "Vital signs twice a day for 2 days, then daily in the A.M." Review of the 2/12 and 3/12 Medication Administration record (MAR) indicated that vital signs were not documented at 9:00 A.M., on 2/28/12, 3/4/12, and 3/11/12 as per medical plan of care.

On 3/13/12 at 4:00 P.M., Unit Manager #2 said the vital signs were not documented as per the medical plan of care.

3. For Patient #3, the hospital failed to document the patient's daily vital signs as per medical plan of care.

Record review on 3/15/12, indicated the patient had a physician's order dated 3/5/12, which read, " Vital signs four times daily for three days." According to the 3/12 MAR , vital signs were not documented on 3/7/12 at 1:00 P.M. and at 11:00 P.M. as per the medical plan of care.

On 3/15/12 at 11:00 A.M., Charge Nurse #3 said the vital signs were not documented as per the medical plan of care.


09115


4. For Patient #26, the hospital failed to document temperatures every four hours in the medical record per the nursing care plan.

Patient #26 was admitted with diagnosis of liver disease and thrombocytopenia.

The nursing care plan for thrombocytopenia had an interventions to monitor temperature every four hours.

Review of the temperature monitoring logs indicated that the patient's temperature was only taken once a day except on 3/8/12 when it was taken three times that day.

5. For Patient #27, the Hospital failed to document wound care as ordered and vital signs daily.

Review of the Medication Administration Record (MAR), indicated a treatment to the stab wound on the patient's left abdomen consisting of a wet to dry dressing daily with normal saline. Review of the MAR indicated the dressing was not signed off as done on 2/28 and 3/2/12 with no explanation why in the clinical record. Daily vitals signs are also documented on the MAR. Review of the MAR indicated no vital signs were documented as done on 3/12 and 3/13/12 without documented reason.

Based on observation, record review, and interviews, the hospital failed to implement an appropriate and effective Infection Control Program for the prevention, control, and investigation of infections and communicable diseases. The Hospital failed to meet the Condition of Participation for Infection Control, as evidenced by:

1. The hospital failed to have an Infection Control Nurse/ Officer in charge of the Infection Control program who had adequate training and experience in infection control to adequately manage and implement the program.

See Atag 0748.

2. The hospital Infection Control Officer failed to develop and implement a system for identifying, controlling and investigating infections of patients and personnel. For example:

a. Review of the infection logs from January 2011 through January 2012 indicated a high incidence of urinary tract infections (UTI) each month. No trending or analysis of the infections was done. Review of Infection Control (IC) data reports to the Quality Assurance Performance Improvement Committee (QAPI) indicated that on 11/30/11, the Infection Control Nurse (ICN) reported the total infection rates for the months of April 2011 through October 2011. The ICN reported that UTIs were the "most common" infection but did not give any statistical data. By surveyor calculations, UTIs were 56% of all hospital infections which the ICN said was accurate during an interview on 3/14/12 at approximately 2:00 P.M. No performance improvement plan was recommended or implemented.

b. Review of the Infection Control committee minutes for January 2011 indicated there was a Norovirus outbreak involving patients and staff. During an interview with the ICN on 3/14/12 at 2:15 P.M, the ICN said the affected staff and patients were not tracked and listed on the infection log.

c. Review of the Infection Control Program, dated 4/28/11, section VII, Methods for Compliance, Implementation and Control, A.2 Handwashing, indicated that handwashing facilities are readily accessible to employees at the Hospital: the facilities are located in laundry rooms as well as many other listed areas.
Observation of the laundry rooms on the North and West Units, on 3/13/12 at 9:00 A.M., indicated no handwashing facilities were available in the rooms. There was no hand sanitizers available either. During an interview with the ICN on 3/14/12 at 2:15 P.M., the ICN said staff and patients should be washing hands after handling dirty personal laundry.
.
d. The hospital failed to minimize the risk of cross contamination during the use of a glucometer to test for fingerstick blood sugar (FSBS for three patients (#10 and NS #A and NS #11 ): and staff failed to implement routine standards of infection control when handling used lancets and contaminated gloves and failed to hand wash between patients.

e. Other breaches of infection control practices observed included removal of contaminated gloves and placing them in the pocket of staff pocket and placing linens on the floor and not in an appropriate container.

See Atag 0749.

3. The hospital failed to have infection control logs that were current and captured all infections.

The logs were not up to date. The most current information was January 2012. The logs were reviewed on 3/14/12. During as interview with the ICN on 3/14/12, at 2:15 P.M. the ICN stated that the logs are a compellation of patients who are on antibiotics for infections.

Review of infection control (IC) log from December 2011 through January 2012, indicated that the log consisted only of patients. The log did not include staff (patient care staff and non-patient care staff, including employees, contract staff and volunteers). The log was not up to date. Information on the logs was only current through January 2012 as of 3/14/12.

The infection control log did not include other types of infections such as communicable diseases i.e., hepatitis, HIV, TB conversions or viral infections, and did not include staff infections as reported to employee health.

See Atag 0750.

4. The Hospital failed to consistently ensure that the hospital-wide quality assurance program and training programs addressed problems identified by the Infection Control Nurse/Officer and implemented successful corrective action plans in affected problem areas.

1. Review of the infection logs from January 2011 through January 2012 indicated a high incidence of urinary tract infections (UTI) each month. No trending or analysis of the infections was done. Surveyor reviewed the data and found that 1/3 to 1/2 of all infections recorded each month were UTIs. Of the total monthly UTIs, 33-50% were hospital acquired.

Review of IC data reports to the QAPI indicated that on 11/30/11, the ICN reported the total infection rates for the months of April 2011 through October 2011. The ICN reported that UTIs were the "most common" infection but did not give any statistical data such as how many were hospital acquired versus how many were community acquired.

No performance improvement plan was recommended or implemented by nursing or the infection control nurse.

See Atag 0756.

Based on review of personnel files and staff interviews, the infection control nurse lacked specialized training in infection control. Findings include:

1. Registered Nurse (RN) #3 was identified during the entrance conference on 3/13/12 at 8:00 A.M., by the hospital administration as the infection control officer/nurse in charge of infection control.

2. Review of RN #3's personnel file indicated the nurse did not have any prior experience in infection control or any prior educational background in infection control. RN #3 had a Bachelor's of Arts degree in Psychology, a Master's degree in Counseling and an Associate's degree in Nursing.

3. Review of continuing education documentation in the inservice education file indicated no evidence of any infection control courses or certifications.

4. On 3/14/12/ at 2:15 P.M., during interview, RN #3 said that he/she had not been to any basic infection control courses and had only exposure to infection control management through nursing school basic training.

Based on observation, record review and interview, the infection control officer failed to develop a system for identifying, controlling and investigating infections of patients and personnel. In addition observations and staff interviews revealed breeches in infection control techniques. Findings include:

1. The hospital lacked an infection log that captured all infections of patients and staff on a real time basis. The current log was only completed up to January 2012 and lacked data such as infecting organism, determination of nosocomial versus community acquired infection.

See A0750.

2. Review of the infection logs from January 2011 through January 2012 indicated a high incidence of urinary tract infections (UTI) each month. No trending or analysis of the infections was done. By surveyor calculations, UTIs were 56% of all hospital infections and 1/3 to 1/2 of all UTIs each month were hospital acquired. During interview, on 3/14/12 at approximately 2:00 P.M., the ICN said this was accurate.

3. Review of infection control (IC) data reports to the Quality Assurance Performance Improvement Committee (QAPI) indicated that on 11/30/11, the infection control nurse (ICN) reported the total infection rates for the months of April 2011 through October 2011 but failed to break down the rates into each infection type. The ICN reported that UTIs were the "most common" infection but did not give any statistical data. By surveyor calculations, UTIs were 56% of all hospital infections which the ICN said was accurate during interview on 3/14/12 at approximately 2:00 P.M. No performance improvement plan was recommended or implemented.

4. Review of the Infection Control committee minutes for January 2011 indicated there was a Norovirus outbreak involving patients and staff. During an interview with the ICN on 3/14/12 at 2:15 P.M, the ICN said the affected staff and patients were not tracked and listed on the infection log. The ICN could not recall how group meetings were handled.

5. Review of the Infection Control Program, dated 4/28/11, section VII, Methods for Compliance, Implementation and Control, A.2 Handwashing, indicated that handwashing facilities are readily accessible to employees at the Hospital: the facilities are located in laundry rooms as well as many other listed areas. The program policy also indicated that staff are expected to wash hands immediately after or as soon possible following contact with blood or other potentially infectious material such as contaminated clothing from patient urine or excrement.

Observation of the laundry rooms on the North and West Units on 3/13/12 at 9:00 A.M., indicated no handwashing facilities were available in the rooms. There was no hand sanitizers available either. On the South Unit, the laundry room had a laundry sink but no hand soap or paper towels for handwashing. All three laundry areas were kept locked and patients were only allowed access to the laundry room in the company of a staff member.

During an interview with the ICN on 3/14/12 at 2:15 P.M., the ICN said staff and patients should be washing hands after handling dirty personal laundry.



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6. The hospital failed to minimize the risk of cross contamination during the use of a glucometer to test for fingerstick blood sugar (FSBS):

Licensed Practical Nurse (LPN) #1 was observed doing FSBS on the South Wing at 11:30 A.M. on 3/14/12 in the dining room. LPN #1 carried the glucometer case holding the glucometer, test strips, finger lancets, and alcohol swabs and placed the case on the table in the dining table. LPN #1, without washing hands, donned a pair of gloves. The LPN removed the meter from the case and scanned non-sampled patient (NS#A's name band and test strip. LPN #1 removed the strip from its wrapper and inserted the strip into the meter. After cleaning NS#A's finger with an alcohol swab, pricking the finger with a lancet and obtaining a blood sample by using both gloved hands, LPN #1 brought the meter up to the patient's finger and placed a drop of blood onto the strip. After obtaining a reading, despite handling the glucometer with contaminated gloves, the LPN removed the strip and placed both the strip and the contaminated lancet into a styrofoam cup. Next, LPN #1 placed the contaminated glucometer back into the case. The LPN removed the contaminated gloves and placed them into the styrofoam cup. The LPN failed to clean the glucometer after use and before returning the glucometer to the storage case, increasing the risk of cross contamination between patients.

The LPN, without washing hands, turned to another patient sitting across the room and followed the above procedure to obtain a FSBS. After obtaining the reading, the LPN placed the contaminated strip, lancet and gloves into the styrofoam cup by 1st pushing down the previous contaminated supplies and then placing these supplies on top.

After washing hands, the LPN brought all of the supplies into the medication room. The LPN donned a pair of gloves and sorted through the styrofoam cup to retrieve the contaminated lancets and placed them into a sharps container. The LPN washed the counter using a bleach wipe. LPN #1 did not disinfect the contaminated glucometer.

Next the LPN removed the gloves and without washing hands brought the glucometer case and a clean styrofoam cup into another non-sampled patient's (NS #11) room to test that patient's FSBS. The LPN placed all of the supplies onto this patient's over the bed table and obtained a blood sugar. After discarding the contaminated supplies into the styrofoam cup including the lancet, alcohol swap, test strip and gloves, the LPN washed her hands using the waterless hand solution.

As the LPN was bringing the supplies back to the medication room, the LPN said that the glucometer is cleaned with bleach as needed and she doesn't clean after each patient use. She also stated that the hospital has portable sharps container which she should bring with her to dispose of the lancets.

On 8/26/2010, the Centers for Disease Control (CDC) issued requirements for Infection Prevention during Blood Glucose Monitoring and Insulin Administration, supported by the Food and Drug Administration (FDA), that state fingerstick devices should never be used for more than one person. Whenever possible, point of care (POC) blood testing devices, such as blood glucose meter and PT/INR anticoagulation meter, should be used only on one patient and not shared. If dedicating POC blood testing devices to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling.

During interview on 3/19/12 at 10:00 a.m., the Infection Control Nurse said that there is a glucometer on each unit, shared by all patients on that unit and must be disinfected, using bleach wipes, after each patient use.

7. Observation on 3/15/12 at 8:15 A.M. revealed the following breeches in infection control:

Milieu Assistant (MA) #1 and MA #2 were attending to Patient #4 who was lying in bed. The patient was incontinent and these 2 MAs were attempting to transfer this patient out of bed and transport to the bathroom. MA #1 was wearing a pair of gloves and after touching the patient and the patient's soiled bed linens, removed the gloves and placed them into her uniform pocket. She then put on another pair of gloves, placed soiled linens on the floor, then attempted to help the patient get up. MA #1 said that she did not know why she put contaminated gloves into her pocket. She also stated that she usually puts linens on the floor and will later pick them up and place then into a linen cart.

During interview with Unit Manager #2, on 3/15/12 at 9:15 A.M., Unit Manager #2 said that soiled linens should not be thrown on the floor, and the MA who put the contaminated gloves into her pocket was nervous.

Based on review of facility documentation and interview with the Infection Control Nurse (ICN) , the Infection Control Nurse failed to maintain a readily accessible and up to date log of incidents related to all infections and communicable diseases, for both patients and staff. Findings included:

1. Review of infection control (IC) logs from December 2011 through January 2012, indicated that the log consisted only of patients. The log did not include staff (patient care staff and non-patient care staff, including employees, contract staff and volunteers).

2. The logs were not up to date. The most current information was for January 2012. The logs were reviewed on 3/14/12. During an interview with the ICN on 3/14/12, at 2:15 P.M., the ICN said that the logs are a compellation of patients who are on antibiotics for infections. The ICN said he completed the logs after receiving a list of patients on antibiotics from the pharmacy which is sent daily. The ICN said he does not work on weekends and reviews the pharmacy lists on Mondays for the weekend past. The ICN stated the logs are not currently up to date, as he had not completed the infection logs with information for February and March as of today 3/14/12.

The infection control log did not include other types of infections such as communicable diseases i.e., hepatitis, HIV, or viral infections, TB conversions and did not include staff infections as reported to employee health. For example: Patient #18 has a diagnosis of Hepatitis C, but was not reported to the ICN for listing on the infection control log. In addition, the ICN said because the data is based on reports from the pharmacy of patients currently on antibiotics, sometimes the patients may have been discharged if over a weekend. The ICN said the floor staff are supposed to call the ICN when someone is admitted with an infection or is on an antibiotic. However, the floor staff do not complete a line listing of potential infections daily and only report if patents are being treated with or started on antibiotics.

3. The ICN said that if staff develop an infection, they are instructed to notify employee health (the ICN). The ICN said records are not kept of reported staff infections, despite a Norovirus outbreak among staff and patients in January 2011. Additionally, the ICN said there was no system to track and monitor infections with volunteers and contract staff.

Based on interview and documentation review, it was determined the Administrator, Medical Staff and Director of Nursing Services failed to consistently ensure that the hospital-wide quality assurance program and training programs addressed problems identified by the Infection Control Nurse/Officer and implemented successful corrective action plans in affected problem areas. Findings included:

1. During the orientation tour on 3/13/12, the Unit Managers on each wing identified the following urinary tract infections (UTIs) in current inpatients: the South Unit identified 5 patients as having UTIs; one patient was identified on the West Wing as having a UTI and one patient on the North wing. During the entrance conference on 3/13/12 at 8:00 A.M., the Director of Nursing said the South Wing housed geri-psychiatric patients who often required more assistance with activities of daily living (ADLs) such as toileting, bathing, grooming and hygiene and often had urinary and bowel incontinence issues.

2. Review of the infection logs from January 2011 through January 2012, indicated a high incidence of UTIs each month. No trending or analysis of the infections was done. By surveyor calculations, UTIs were 56% of all hospital infections and 1/3 to 1/2 of all UTIs each month, were hospital acquired. During interview, on 3/14/12 at approximately 2:00 P.M., the ICN said this was accurate.

3. Review of IC data reports to the Quality Assurance Performance Improvement Committee (QAPI) indicated that on 11/30/11, the ICN reported the total infection rates for the months of April 2011 through October 2011. The ICN reported that UTIs were the "most common" infection but did not give any of the statistical data. No performance improvement plan was recommended or implemented.

4. During an interview, on 3/19/2012 at approximately 10:00 A.M., the ICN, who is also the staff educator (SDE) and the DON both said that personal care such as incontinence care is provided by milieu assistants (MA), some who were previously certified nurses' aides. The ICN/SDE said there is no orientation provided upon hire to new MA on how to provide personal care for ADLs. The DON said that each new MA works with an experienced MA for five days and learns to provide personal care from that person. During continued interview, the SDE/ICN said there is no validation of competency to ensure that the MA is providing safe and effective personal care with patient ADLs, including incontinence care to minimize UTIs.

Based on interviews with the Director of Nurses [DON] and the Assistant Director of Performance Improvement [PI] and review of the hospital's contract with the organ procurement organization, the hospital failed to ensure that all clinical and medical staff were educated on donation issues.

Findings include:

During interview at 8:45 A.M. on 3/14/12, the DON and the Director of PI said that hospital policy indicated that the hospital staff would inquire as to whether a patient already had an organ donor card, but would not ask if the patient wished to be an organ donor.

The DON and the Director of PI further said that if a patient died, all unit managers and supervisors were responsible for contacting the New England Organ Bank. During the interview, it was further indicated that all staff had received initial training, but had not been trained in a program which was developed in cooperation with the Organ Procurement Organization.

Based on record review and interview, the facility failed to:

1. Ensure that treatment goals on the Master Treatment Plans (MTP) were individualized and met the specific treatment needs of 8 of 8 active sample patients (N3, N15, S1, S7, S13, W9, W11 and W19). The facility used identical preprinted treatment plan forms for all patients, which resulted in the selection of identical treatment goals for each of the above patients regardless of individual problems and needs. This practice compromises the ability of the treatment team to effectively address each patient's specific problems and needs, potentially prolonging patients' readiness for discharge. (Refer to B121)

2. Ensure that the Master Treatment Plans of 8 of 8 active sample patients (N3, N15, S1, S7, S13, W9, W11 and W19) identified active treatment measures that addressed the individual patients' specific problems and needs. The interventions on the identical preprinted MTP forms listed routine and generic discipline functions incorrectly regarded as individualized treatment interventions. This failure results in a lack of guidance for staff in providing individualized approaches to patient care that is purposeful and goal directed. (Refer to B122)

3. Ensure that active treatment measures were provided for 2 of 8 active sample patients (S1 and W19). In the case of patient S1, there was a failure to provide individualized structured psychiatric treatment for this patient who was not attending scheduled programming. In the case of patient W19, in addition to psychiatric problems, the patient had previously experienced a stroke; despite recommendations from the admitting physician and physical therapist, the facility did not provide ongoing occupational therapy. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery provided in a timely fashion, potentially delaying their clinical improvement. (Refer to B125)

Based on record review, policy review and staff interview, the facility failed to ensure that 8 of 8 active sample patients (S1, S7, S13, N3, N15, W9, W11 and W19) received a psychiatric evaluation containing an inventory of each patient's assets that would be used in treatment. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized plans of care for their patients and limits the team's ability to engage patients in therapy.

Findings include:

A. Record Reviews

No description of assets or strengths were listed in the Initial (Admission) Psychiatric Evaluations of patients S1 (dictated on 03/09/2012), S7 (dictated on 02/22/2012), S13 (dictated on 02/10/2012), N3 (dictated on 03/12/2012), N15 (dictated on 03/02/2012), W9 (dictated on 03/09/2012), W11 (dictated on 03/08/2012), or W19 (dictated on 02/22/2012).

B. Policy Review:

1. Whittier Pavilion Policy# PC-02 "Attending Physician Responsibilities and Coverage" states, "An attending physician must complete an Initial Psychiatric Evaluation of all admissions within 24 hours." No details regarding the organization and content are described.

2. Whittier Pavilion Policy# ASM-14 "Psychiatric Evaluation" states, "The psychiatric evaluation includes, but is not limited to: history of cognitive, emotional, and behavioral problems and of prior treatment; current cognitive, emotional, and behavioral functioning; co-occurring conditions, including substance use, problem gambling, and other addictive behavior as well as medical issues; resources in the community (treatment, assistive, and supportive) utilized by the patient; mental status assessment; risk assessment; diagnosis; clinical formulation." Description of assets or strengths is not mentioned.

C. Staff Interview

During interview on 03/14/12 at 1:15pm, the Medical Director acknowledged he did not perform any formal chart reviews or utilize a peer review process for review of the quality of documentation of the psychiatric assessments.

Based on record review and interview, the facility failed to ensure that treatment goals on the Master Treatment Plans (MTPs) were individualized and met the specific treatment needs of 8 of 8 active sample patients (N3, N15, S1, S7, S13, W9, W11 and W19). The facility used identical preprinted treatment plan forms which resulted in the selection of identical treatment goals for each patient regardless of individual problems and needs. This practice compromises the ability of the treatment team to effectively address each patient's specific problems and needs, potentially prolonging their readiness for discharge.

Findings include:

A. Record Review

1. Active sample patient N3, MTP dated 3/13/12- The identified psychiatric problem was "SI [suicidal ideation], rt [related to] depression - danger to self."
The pre-printed short term goals were:

- "patient will maintain safety and/or report impulse to hurt self/others to staff throughout the day."

- "patient will sleep 6+ hrs [hour]/night, perform ADL's [activities of daily living], eat 3 meals/day, and attend offered groups daily."

- "patient will take medications as prescribed, report efficacy/side effects daily, and participate in education re[about] diagnosis/treatment."

- "patient will report disruptions in thoughts or presence of hallucinations or delusions to staff, if present."

- "patient will participate in psychosocial evaluation and identify needs/involve family members and caregivers within 24 hours of initial treatment plan."

- "patient will participate in scheduled discharge planning meetings, voice preferences and allow appropriate referrals & [and] communication with support 2 - 3 x/week [times per week]."

2. Active sample patient N15, MTP dated 3/5/12- The identified psychiatric problems were: "depression/SI/ETOH [alcohol] abuse - danger to self."
The short term goals were the same as patient N3's listed above.

3. Active sample patient S1, MTP dated 3/9/12- The identified psychiatric problem was: "Alzheimer - danger to others."
The short term goals were the same as patient N3's listed above.

4. Active sample patient S7, MTP dated 2/22/12- The identified psychiatric problem was: "Dementia - danger to others."
The short term goals were the same as patient N3 ' s listed above.

5. Active sample patient S13, MTP dated 2/13/12- The identified psychiatric problem was: "Dementia - inability to care for self."
The short term goals were the same as patient N3's listed above.

6. Active sample patient W9, MTP dated 3/12/12- The identified psychiatric problem was: "Inability to care for self."
The short term goals were the same as patient N3 ' s listed above.

7. Active sample patient W11, MTP dated 3/8/12- The identified psychiatric problems were: "SI, panic attacks, agoraphobia - danger to self."
The short term goals were the same as patient N3's listed above.

8. Active sample patient W19, MTP dated 2/23/12- The identified psychiatric problem was: "Depression, helplessness, hopelessness - danger to self."
The short term goals were the same as patient N3's listed above.

B. Interviews

1. In an interview on 3/14/12 at 12:49p.m., which included a discussion of the generic goals on the pre-printed Master Treatment Plan forms, the Nursing Director agreed with the findings and stated, "We need to go back to the drawing board and start over." She was referring to the development of new treatment plan forms.

2. In an interview on 3/14/12 at 1:15p.m., it was pointed out to the Medical Director that many of the "short term goals" on the Master Treatment plans were generic and lack specificity for any given patient. The Medical Director agreed and stated, "I've struggled for years with treatment plans."

Based on record review and interview, the facility failed to ensure that the treatment plans of 8 of 8 active sample patients (N3, N15, S1, S7, S13, W9, W11 and W19) identified active treatment measures that addressed the individual patients' presenting problems and needs. Instead, the treatment interventions on the preprinted MTP forms listed routine and generic discipline functions incorrectly written as treatment interventions. This failure results in a lack of guidance for staff in providing individualized approaches to patient care that is purposeful and goal directed.

Findings include:

A. Record Review

1. Facility policy # TR-01, titled "Interdisciplinary Treatment Team Meeting", last reviewed 11/8/10, focused primarily on the organization and functions of treatment team meetings. There was no mention of quality and development of treatment plan components, including treatment interventions.

2. Active sample patient N3, Mater Treatment plan (MTP) dated 3/13/12- The identified psychiatric problem was: "SI [suicidal ideations], rt [related to] depression - danger to self."
The preprinted generic interventions were:
Physician - "Monitor mood/safety every shift and in daily rounds and encourage use of coping skill; adjust restrictions [sic], offer supportive and cognitive reframing as indicated."

nurses - "Monitor sleep, appetite, grooming every shift and encourage patient to maintain healthy habits and attend/participate in groups."

Physician/nurses "Educate patient regarding medications in daily rounds, medication groups and meetings with nursing. Adjust medications as indicated with patient input and evaluate efficacy and effect" and "Monitor though process in daily rounds and every shift, reality test/educate/offer prns [as needed] and encourage use of coping skills when indicated."

Social workers - "Meet with patient in daily rounds re-evaluate current support system and determine patients need and wishes regarding after care"; "Initiate referrals to appropriate agencies and caregiver pursuant to patient needs and wishes" and
"Coordinate treatment and discharge planning with current support."

3. Active sample patient N15, MTP dated 3/5/12- The identified psychiatric problems were "depression/SI/ETOH [alcohol] abuse - danger to self."
The interventions were the same as patient N3's listed above.

4. Active sample patient S1, MTP dated 3/9/12-The identified psychiatric problem was "Alzheimer - danger to others."
The interventions were the same as patient N3's listed above.

5. Active sample patient S7, MTP dated 2/22/12- The identified psychiatric problem was "Dementia - danger to others."
The interventions were the same as patient N3's listed above.

6. Active sample patient S13, MTP dated 2/13/12- The identified psychiatric problem was "Dementia - inability to care for self."
The interventions were the same as patient N3's listed above.

7. Active sample patient W9, MTP dated 3/12/12- The identified psychiatric problem was "Inability to care for self."
The interventions were the same as patient N3's listed above.

8. Active sample patient W11, MTP dated 3/8/12- The identified psychiatric problem were "SI, panic attacks, agoraphobia - danger to self."
The interventions were the same as patient N3's listed above.

9. Active sample patient W19, MTP dated 2/23/12- The identified psychiatric problem was "Depression, helplessness, hopelessness - danger to self."
The patient interventions were the same as patient N3's listed above.

B. Interviews

1. In an interview on 3/14/12 at 9:03a.m., RN2 was asked if s/he thought the Master Treatment plans were individualized. RN2 stated, "They aren't, but we're working on that."

2. In an interview on 3/14/12 at 12:40p.m., the generic interventions on the Master Treatment plan were discussed with the Nursing Director. She agreed with the findings and stated, "We need to go back to the drawing board and start over." (She was referring to the development of revised treatment plan forms.)

3. In an interview on 3/14/12 at 1:15p.m., the Medical Director agreed that the interventions on the Master Treatment plans were all the same and that they lacked any individual specificity related to a given patient's particular issues. The Medical Director agreed that if the patients' names on the MTP were covered, staff would not be able to identify one patient's plan from another.

Based on observations, record review and interviews, the facility failed to ensure that active treatment measures were provided to 2 of 8 active sample patients (S1 and W19). In the case of patient S1, there was a failure to provide individualized structured psychiatric treatment for this patient who was not attending scheduled programming. In the case of patient W19, in addition to psychiatric problems, the patient had experienced a stroke; despite recommendations from the admitting physician and the physical therapist, the facility did not provide ongoing occupational therapy. Failure to ensure active treatment results in patients being hospitalized without all interventions for recovery provided in a timely fashion, potentially delaying their improvement.

Findings include:

A. Active sample patient S1

1. According to the psychiatric evaluation, dated 3/9/12, patient S1 "had a 3-year history of dementia with no known patient treatment" ..."[patient] was referred [for inpatient care]...for increased agitation and aggressive behavior towards [spouse].... [patient] has a long standing history of depression without outpatient treatments....[Patient] has become more and more irritable and frequency of agitation has increased....The patient will attend groups and activities as [patient] tolerates."

2. On patient S1's Master Treatment plan, dated 3/9/12, the identified psychiatric problem was "Alzheimer - danger to others." The listed interventions included "adjust medications as indicated with patient input and evaluate care and side effects" (physician); "educate patient regarding medication in daily rounds, medication group and meetings with nursing" (nursing); "coordinate treatment and discharge planning with current supports" (social workers); "provide daily socialization" (therapeutic programs)

3. A review of South Unit's group schedule on 3/14/12 at 1:30p.m. with the Director of Therapeutic programs revealed that 4 therapeutic groups were offered for all patients daily during the week by occupational staff (O.T.) between the hours of 9:30a.m. and 3:30p.m. The 20 groups during weekdays were: 9:30a.m. - 10:15a.m. - "Community Meeting/goals group", "Expressive therapy or exercise" groups from 10:45a.m. - 10:30a.m., "Purposeful activities, music, or reminiscence " groups from 12:45p.m. - 1:30p.m., and "open recreation or games group" from 2:45p.m. - 3:30p.m. In an interview on 3/14/12 at 1:30p.m, the Therapeutic Activity's director stated that there was one schedule for each patient unit. All patients were expected to attend the groups on the unit schedule unless assigned to a substance abuse group at the same time.

4. Patient S1 was observed lying on his/her bed with eyes closed on 3/13/12 between 10:20a.m. and 11:30a.m while an "Exercise" group was being held in the South dining room between 10:45a.m. and 11:30a.m. Unit staff was observed doing round checks, but no staff member was observed trying to encourage the patient to attend the scheduled group.
Patient S1 was observed sitting at a scheduled "Goals" group in South's unit dining room on 3/14/12 at 9:40a.m. The patient sat quietly at a table with two other patients, but did not verbally participate in the group discussion. Patient S1 left the group at 9:43a.m. Neither of the 2 staff members present in the group asked patient S1 why s/he was leaving the group.

5. A review of patient S1's attendance sheet for the period of 3/9/12 to 3/13/12 showed that S1 attended 4 groups out of 16 offered during this period. On 3/9/12, Patient S1 attended 1 ("Goals") of the 4 scheduled groups. On 3/10/12, S1 attended the 10:45a.m. "Exercise" group. On 3/12/12 and 3/13/12, S1 attended the 9:30a.m. "Goals" group.

6. A review of S1's rounds sheet [documentation of where patient is during 15 minutes intervals] revealed that during group meetings, with the exception of the 4 groups attended, S1 was in his/her bedroom, in the "Sensory" room (a open room that patients can go to voluntarily for quiet time), or in the hallway.

7. In an interview on 3/14/12 at 9:00a.m., MHT1 was asked about S1's lack of attendance at groups and how the staff handled situations like that. MHT1 stated that nursing staff invite patients to go to groups several times, but can do nothing if they don't go.

8. In an interview on 3/14/12 at 9:24a.m., the lack of patient S1's attendance at scheduled groups was discussed with MD1. MD1 acknowledged that he was aware of S1's poor group attendance and stated, "[Patient] has not been here long enough [to worry about group attendance] - only 5 days or so [the average length of stay is 9 days]. Sometimes we have to pick and choose our battles." MD1 did agree that some alternative, other than groups, could be considered.

B. Active sample patient W19

1. Patient W19, per Psychiatric Evaluation dated 2/22/12, had "an Axis I diagnosis of Schizoaffective Disorder complicated by a cerebrovascular accident that left the patient with left-sided upper extremity paresis (weakness), left-sided facial droop, and left lower extremity weakness requiring the use of a brace." The physician performing the admission physical examination (date of exam: 2/22/12) noted "[increased] neuropathy since stroke," and listed "s/p [status post] CVA [cerebrovascular accident] with left-sided deficit;" and noted "P.T. /O.T. plan tx [physical therapy, occupational therapy plan treatment]" in the "assessment/plan" section of the examination report. In addition, the consulting physical therapist noted "s/p CVA...rehab X 1 month - just returned home...unable to care for [him/her]self" in the "Relevant Patient History" section of the "Physical Therapy Initial Evaluation" report. In addition, the report stated "left hand/fingers [decreased] rom [range of motion] left UE [upper extremity] prox 2/5 [proximal strength of 2 on a scale of 5] distal 1-2/5 [distal strength of 1-2 on a scale of 5]" when describing strength and movement. In the "assessment" section of the report, "ongoing OT treatment" was recommended "to address ADL deficits and left UE/hand rom."

2. There was no record of the provision of occupational therapy in the medical record documentation.

3. The Director of Therapeutic Activities and COTA-L1 were interviewed on 3/13/12 at 2:10p.m. The Director responded, "We don't provide OT, PT, or speech therapy. Our programming doesn't include OT, PT, or speech therapy." COTA-L1 responded, "we've never done phys-med [physical medicine] OT here. I'm psych." The Director further stated, "We've never done physical medicine OT."

4. Patient W19 was interviewed on 3/13/12 at 2:10p.m.When asked about treatment, W19 responded, "I wish I could get OT and PT. I can't use my left arm or hand at all....I rub it and put lotion on it." When asked how s/he managed with use of the bathroom given that s/he could not use it without assistance, W19 answered, "Sometimes I can't get anyone to help me."

Based on record review and interview, the Medical Director failed to monitor the quality and appropriateness of clinical care rendered. Specifically, the Medical Director failed to:

I. Ensure that (a) the psychiatric evaluations contained an inventory of the patient's assets to be used in treatment for 8 of 8 active sample patients (S1, S7, S13, N3, N15, W9, W11 and W19); and (b) the facility's policy ASM-14 "Psychiatric Evaluation" clarified that the psychiatric evaluation include an inventory of assets that would be used in planning treatment. This deficient practice results in insufficient information to guide the treatment team in developing appropriately individualized plans of care for their patients and limits the team's ability to engage patients in therapy (Refer to B117).
During interview on 03/14/12 at 1:15pm, the Medical Director acknowledged he did not perform any formal chart reviews or utilize a peer review process for review of the quality of documentation of the psychiatric assessments.

II. Ensure that treatment goals on the Master Treatment Plans (MTPs) were individualized and met the specific treatment needs of 8 of 8 active sample patients (N3, N15, S1, S7, S13, W9, W11 and W19). The facility did not have a treatment plan policy that focused on how to develop individualized Master Treatment plans. The only treatment plan policy (#TR-01, titled "Interdisciplinary Treatment Team Meeting," last reviewed 11/8/10) did not include any reference to necessary components of a care plan.

The facility used preprinted treatment plan forms which resulted in the selection of identical treatment goals for each of the sample patients regardless of individual problems and needs. This practice compromises the ability of the treatment team to effectively address patients' specific problems and needs, potentially prolonging their readiness for discharge. (Refer to B121)

III. Ensure the Master Treatment Plans of 8 of 8 active sample patients (N3, N15, S1, S7, S13, W9, W11 and W19) identified active treatment measures that addressed the individual patients presenting problems and needs. Instead, the treatment interventions on the preprinted MTP forms listed routine and generic discipline functions inappropriately written as treatment interventions. This failure results in a lack of guidance for staff in providing individualized approaches to patient care that is purposeful and goal directed. (Refer to B122)

In an interview on 3/14/12 at 1:15p.m., the Medical Director agreed that the interventions on the Master Treatment plans were all the same and that they lacked any individual specificity related to a given patient's particular issues. The Medical Director agreed that if the patients' names on the MTP were covered, staff would not be able to identify one specific patient's plan from another.

IV. Ensure that active treatment measures were provided to 2 of 8 active sample patients (S1 and W19). In the case of patient S1, there was a failure to provide individualized structured psychiatric treatment for this patient who was not attending scheduled programming. In the case of patient W19, in addition to psychiatric problems, the patient had experienced a stroke; despite recommendations from the admitting physician and the physical therapist, the facility did not provide ongoing occupational therapy. These failures to ensure active treatment results in the patients being hospitalized without all interventions for recovery provided in a timely fashion, potentially delaying their improvement. (Refer to B125)

Based on record review and interview, the Nursing Director failed to ensure the quality and appropriateness of nursing care. Specifically, the Nursing Director failed to ensure that the Master Treatment Plans of 8 of 8 active sample patients (N3, N15, S1, S7, S13, W9, W11 and W19) identified active treatment measures, addressing the individual patients ' presenting problems and needs. Instead, the treatment interventions on the preprinted MTP form listed routine and generic nursing functions inappropriately written as treatment interventions. This failure results in a lack of guidance for nursing staff in providing individualized approaches to patient care that is purposeful and goal directed.

Findings include:

1. Facility policy # TR-01, titled "Interdisciplinary Treatment Team Meeting," last reviewed 11/8/10, focused primarily on the organization and functions of treatment team meetings. There was no mention of quality and development of treatment plan components, including treatment interventions.

2. Active sample patient N3, Mater Treatment plan (MTP) dated 3/13/12- The identified psychiatric problems were "SI [suicidal ideations], rt [related to] depression - danger to self."
The preprinted generic nursing interventions were:

"Monitor mood/safety every shift and in daily rounds and encourage use of coping skills; adjust restrictions, offer supportive and cognitive reframing as indicated."

"Monitor sleep, appetite, grooming every shift and encourage patient to maintain healthy habits and attend/participate in groups";

"Educate patient regarding medications in daily rounds, medication groups and meetings with nursing. Adjust medications as indicated with patient input and evaluate efficacy and effect"

"Monitor thought process in daily rounds and every shift, reality test/educate/offer prns [as needed] and encourage use of coping skills when indicated."

3. Active sample patient N15, MTP dated 3/9/12- The identified psychiatric problems were "depression/SI/ETOH [alcohol] abuse - danger to self."
The nursing interventions were the same as patient N3's listed above.

4. Active sample patient S1, MTP dated 3/9/12- The identified psychiatric problem was "Alzheimer - danger to others."
The nursing interventions were the same as patient N3's listed above.

5. Active sample patient S7, MTP dated 2/29/12-The identified psychiatric problem was "Dementia - danger to others."
The nursing interventions were the same as patient N3's listed above.

6. Active sample patient S13, MTP dated 2/14/12- The identified psychiatric problem was "Dementia - inability to care for self."
The nursing interventions were the same as patient N3's listed above.

7. Active sample patient W9, MTP dated 3/12/12- The identified psychiatric problem was "Inability to care for self."
The nursing interventions were the same as patient N3's listed above.

8. Active sample patient W11, MTP dated 3/8/12- The identified psychiatric problem were "SI, panic attacks, agoraphobia - danger to self."
The nursing interventions were the same as patient N3's listed above.

9. Active sample patient W19, MTP dated 3/1/12- The identified psychiatric problem was "Depression, helplessness, hopelessness - danger to self."
The nursing interventions were the same as patient N3's listed above.

B. Staff Interviews

1. In an interview on 3/14/12 at 9:03a.m., RN2 was asked if s/he thought the Master Treatment plans were individualized. RN2 stated, "They aren't, but we're working on that."

2. In an interview on 3/14/12 at 12:40p.m., the generic interventions on the Master Treatment plan was discussed with the Nursing Director. She agreed with the findings and said, "We need to go back to the drawing board and start over." She was referring to the development of revised treatment plan forms.