HospitalInspections.org

Based on record review, observation and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure staff conducted safety observations on psychiatric patients every 15 minutes as ordered by the physician for 1 patient room containing 2 (#3, #4) current patients out of a total of 3 rooms containing 6 patients (#2, #3, #4, #R2, #R3, #R4) visible on the hospital provided video footage (see findings tag A-0144).

2) Failing to develop a system/policy for the RN to supervise the MHT's documentation of the observation of patients for 5 (#2, #3, #4, #6, #7) of 10 (#1 - #10) patient records reviewed for MHT patient observation records from a total of 17 sampled patients (see findings tag A-0144).

30984


Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by:
1) failing to ensure staff conducted safety observations on psychiatric patients every 15 minutes as ordered by the physician for 1 patient room containing 2 (#3, #4) current patients out of a total of 3 rooms containing 6 patients (#2, #3, #4, #R2, #R3, #R4) visible on the hospital provided video footage; and

2) Failing to develop a system/policy for the RN to supervise the MHT's documentation of the observation of patients for 5 (#2, #3, #4, #6, #7) of 10 (#1 - #10) patient records reviewed for MHT patient observation records from a total of 17 sampled patients; and

3) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for geriatric psychiatric patients admitted for being a danger to self or others.


Findings:

1) Failing to ensure staff conducted safety observations on psychiatric patients every 15 minutes as ordered by the physician:

Review of the facility policy titled 15 Minute Check Sheet revealed in part:
A designated MHT will note and document on the rounds sheet the location of patients every fifteen minutes.
1) A every 15 minute sheet will be initiated by each night shift.
2) An MHT will be assigned the responsibility of observing and documenting patient rounds every 15 minutes.

Review of Patient #3's medical record revealed she was admitted on 06/08/17 at 7:20 p.m. with diagnosis which included Dementia with behavioral disturbances. Further review revealed she was ordered to be on 15 minute safety observations and fall precautions.

Review of Patient #4's medical record revealed she was admitted on 06/08/17 at 8:50 p.m. with diagnosis which included Bipolar 1 disorder with psychotic behavior. Further review revealed she was ordered to be on 15 minute safety observations and fall precautions.

An observation was made with S2ADON (Acting DON) on 06/14/17 beginning at 10:30 a.m. of recorded video footage of the patients' hallway in the hospital. The time period observed was 06/11/17 from 1:00 a.m. until 3:00 a.m. Observation revealed no staff member observed the patients in Room "A" (Patients #3 and #4) from 1:00 a.m. until 3:00 a.m. (2 hours).

Review of documents in Patient #3's and Patient #4's medical records titled 15 Minute Checks Patient Observation Records dated 06/11/17 revealed S22MHT had initialed he had observed the 2 patients every 15 minutes from midnight to 3:45 a.m.

In an interview on 06/14/17 at 11:10 a.m. with S2ADON, she verified no staff member had made any observations on Patient #3 or #4 for 2 or more hours on 06/11/17. S2ADON said nobody checking on the 2 patients in Room "A" for 2 hours was unacceptable. She said somebody should have checked on them every 15 minutes. S2ADON verified S22MHT documenting that he checked on the 2 patients every 15 minutes was false documentation.

In an interview on 06/14/17 at 1:00 p.m. with S1Adm, he said the staff not checking on the patients for 2 hours instead of every 15 minutes as ordered was unacceptable.

In an interview on 06/14/17 at 12:54 p.m. with S5RN, she said she worked 06/10/17 at 6:00 p.m. through 6:15 a.m. on 6/11/17 and was in charge. S5RN said she does not assign a certain patient to a certain technician. She also said she usually tried to make rounds every hour, but at night she made rounds every 2 hours. S5RN said she did not know until today that the RN was required to round on the patients every hour. S5RN verified Patient #3 and Patient #4 should have been monitored every 15 minutes and 2 hours out of sight was unacceptable.

In an interview on 06/14/17 at 1:45 p.m. with S22MHT, he said he was working from 6:00 p.m. on 06/10/17 and left at 6:00 a.m. on 06/11/17. S22MHT said he was sitting with a patient in Room "B" who was a fall risk and combative. S22MHT said at other facilities he worked he had a patient assignment but at this hospital all of the MHTs were responsible for all of the patients. S22MHT said that was not a good system because nobody was responsible for a particular patient. S22MHT said he was wrong and he was sorry but he did not observe Patient #3 or Patient #4 from 6:00 p.m. until 3:45 a.m. but he documented that he had observed them every 15 minutes. He said he only observed the patients in Room "B" the night of 06/10/17. He said he could not assure the 2 patients in Room "A" were safe. He also said both patients were also fall risks. S22MHT said nobody watches the patients as ordered. He said there was disorganization on the unit and they needed structure. S22MHT said he filled out the observation sheets on other MHT's patients although he did not observe them and the MHTs did not communicate about the patients status every 15 minutes. He said S5RN knew he was not checking on the patients in Room "A".


2) Failing to develop a system/policy for the RN to supervise the MHT's documentation of the observation of patients.

Review of the policy titled "15 Minute Check Sheet", presented as a current policy by S2ADON, revealed that a designated MHT will note and document on the rounds sheet the location of patients every 15 minutes. Any out of the usual occurrences will be brought to the attention of the charge nurse. Further review revealed no documented evidence that the policy addressed the RN's responsibility to assure that documentation by the MHT was accurate and complete.

Review of the policy titled "Levels of Patient Observation", presented as a current policy by S1ADON, revealed that the charge RN, in conjunction with staff providing direct patient care, is responsible for assessing the observation status of all patients. Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks.


Patient #2
Review of Patient #2's "Admission Orders", dated 06/09/17, revealed orders for special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #2's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the ordered special precautions (patient is on fall precautions) on 06/09/17 and 06/10/17. Further review revealed on 06/11/17 and 06/12/17 both the observation level and special precautions (fall) were left blank.

Patient #3
Review of Patient #3's "Admission Orders" revealed special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #3's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the date, level of observation, and fall precautions on the record initiated the day of admit (06/08/17). Further review revealed the record did not include fall precautions on 06/09/17 and 06/10/17. Further review revealed the record didn't include the level of observation and fall precautions on 06/11/17 and 06/12/17.

Patient #4
Review of Patient #4's "Admission Orders" dated 06/08/17 revealed special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #4's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the date, level of observation, and fall precautions on the record initiated the day of admit (06/08/17). Further review revealed the record did not include fall precautions on 06/09/17, 06/10/17, 06/11/17, and 06/12/17.


Patient #6
Review of Patient #6's "Admission Orders", dated 05/31/17, revealed orders for special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #6's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the ordered special precautions (patient is on fall precautions) on 06/01/17, 06/02/17, 06/03/17, 06/04/17, 06/05/17, 06/06/17, 06/07/17, 06/08/17, 06/09/17, and 06/10/17. Further review revealed on 05/31/17, 06/11/17, and 06/12/17 both the observation level and special precautions (fall) were left blank on Patient #6's observation records.

Patient #7
Review of Patient #7's medical record revealed orders for special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #7's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of fall precautions as a special precaution on 05/26/17, 05/27/17, 05/28/17, 05/29/17, 05/30/17, 05/31/17, 06/01/17, 06/02/17, 06/03/17, 06/04/17, 06/05/17, 06/06/17, 06/08/17, 06/09/17, and 06/10/17. Further review revealed no documented evidence of the level of observation and fall precautions on 06/07/17, 06/11/17, and 06/12/17.

In an interview on 06/14/17 at 1:15 p.m., S5RN indicated the MHT's observation is prepared on the night shift by a MHT for the next day. She further indicated she wasn't aware of a process or policy that required the RN to review the MHT's patient observation records for completeness and accuracy. She indicated that the nursing staff considers each patient a fall risk, so they fall precautions isn't listed on the patient's observation record.

In an interview on 06/14/17 at 1:45 p.m., S2ADON confirmed that fall precautions should be documented on the MHT's patient observation records. She confirmed that the nurse doesn't review the MHT's observation records.


3) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for geriatric psychiatric patients admitted for being a danger to self or others.

On 06/13/17 at 8:55 a.m. an observation was made of the hospital's patient care area with S2ADON. There were 8 double occupancy patient rooms located down a single hallway in view of the nurse's station.

The following ligature and safety risks were observed:

1) Patient rooms #1-#6: Observed patient beds were noted to be adjustable, metal-framed, hospital-type beds with 4 open-framed ¼ side rails (2 - 1/4 rails per each side of the bed). The beds also had headboards and footboards. The beds provided multiple potential ligature points. There were a total of 12 hospital-type beds located in rooms #1-#6.

2) Non-tamper resistant screws observed in the patient room windowsills, door faceplates, and "Honeywell' solid metal faceplates in all patient rooms (confirmed all patient rooms were constructed the same way with the same hardware with S2ADON during the observation).

In an interview on 06/13/17 at 9:20 a.m., during the observation, with S2ADON, she confirmed the above referenced findings and agreed they could be a potential patient safety risk. S2ADON indicated the hospital-type beds with side rails were used as a fall prevention measure for the geriatric psychiatric patients. She confirmed the beginning admission age for the hospital was 50. She also confirmed the hospital had 4 box-style beds in rooms 7 and 8 and these beds were utilized for patients who were assessed as being at risk for suicide/on suicide precautions. S2ADON further confirmed the hospital did not have any other type of beds except for the bed types referenced above.

Based on record review and interview, the hospital failed to ensure all direct care staff had education, training, and demonstrated competence in the use of non-physical intervention skills. This deficient practice was evidenced by failure of the hospital to train 4 (S16ST, S17PT, S18PT, S21RD) of 4 contracted employees, who interacted directly with patients, in the use of non-physical intervention skills for crisis prevention (EDGE training) out of a total of 4 contracted employee personnel records reviewed.

Findings:

Review of the "2017 Staff Development Plan", presented as the current plan by S8HR, revealed that all staff will demonstrate the appropriate knowledge and skills necessary to provide quality care/service appropriate to any age/disability related needs of the patients served. Employees with direct patient care responsibilities will obtain and maintain current certification in EDGE. Employees must attend certification classes which are routinely held on-site.

Review of the personnel files of S16ST, S17PT, and S18PT revealed no documented evidence of EDGE certification.

In an interview on 06/15/17 at 9:45 a.m., S1Adm was informed of the above findings related to the personnel file reviews of S16ST, S17PT, and S18PT. He offered no explanation for not having documented evidence of EDGE certification for S16ST, S17PT, and S18PT.

Review of the personnel file for S21RD (Registered Dietician) revealed no documented evidence of EDGE certification.

In an interview on 06/14/17 at 1:47 p.m. with S21RD, she indicated patient dietary counseling (face to face patient meeting/interaction) was part of the contracted dietary services that she provided.

In an interview on 06/15/17 at 1:00 p.m. with S8HR (Human Resources), he confirmed S21RD did not have current EDGE certification.




30984

Based on record review and interview, the hospital failed to ensure the QAPI Program measured, analyzed, and tracked all adverse patient events.

Findings:

Review of an occurrence report dated 02/24/17 revealed on 02/23/17 Patient #12 was eating in the cafeteria when he choked on his food. He eventually became unresponsive and was transferred to a local acute care hospital where he later expired. Further review revealed no documented evidence the event had been thoroughly investigated and reviewed for quality assurance performance improvement activities.

In an interview on 06/15/17 at 8:20 a.m. with S1Adm, he verified there was no documentation of analyzing, tracking or trending adverse events. He verified S23DON reviewed the video recording about Patient #12 choking but did not investigate or analyze the incident for quality purposes.

Based on record review and interview, the hospital's governing body failed to ensure that the program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by the hospital's failure to include all contracted services in the hospital's QAPI program.

Findings:

Review of the QAPI data provided by the facility revealed no data was tracked, trended and analyzed for the contracted services of medical waste, physical therapy, speech therapy or linen services.

In an interview on 06/15/17 at 8:22 a.m. with S1Adm, he verified all contracted services were not included in the QAPI program.

25065

Based on record reviews and interview, the hospital failed to ensure the medical staff examined the credentials of eligible candidates for medical staff membership and made recommendations to the governing body on the appointment in accordance with the medical staff by-laws and rules and regulations as evidenced by failure to implement the medical staff by-laws related to credentialing for 3 (S6MedDir, S9MD, S10MD) of 4 (S6MedDir, S9MD, S10MD, S11MD) physician credentialing files reviewed for implementation of the credentialing process in accordance with the hospital's medical staff by-laws.
Findings:

Review of the Medical Staff By-laws, presented as the current by-laws by S3MedRecords, revealed that medical staff members will be reappointed every two years. The Medical Director shall review all pertinent information available on each practitioner scheduled for reappointment for the purpose of determining its recommendations for reappointments to the Medical Staff and for granting of clinical privileges for the ensuing period, and shall transmit its recommendations, in writing, to the Governing Board. Each recommendation concerning the reappointment of a Medical Staff member and the clinical privileges to be granted upon reappointment shall be based upon the member's professional and clinical performance, including current privileges and the basis for any requested modification. The Medical Director shall make verbal recommendations to the Governing Board, through the Administrator, concerning the reappointment, non-reappointment, and/or clinical privileges of each practitioner then scheduled for periodic appraisal (contradictory to earlier statement that recommendations have to in writing). Further review revealed every initial application for staff appointment must contain a delineation of the specific clinical privileges desired by the applicant. Applications for additional clinical privileges must be in writing. There was no documented evidence that the by-laws addressed whether a request for clinical privileges had to be submitted with each application for reappointment.

S6MedDir
Review of S6MedDir's credentialing file revealed he recommended himself to the Governing Board on 07/13/16 for active membership with privileges approved as requested. Further review revealed the delineation of privileges request attached to his "Request For Medical Staff Reappointment" was dated 01/09/08.

In an interview on 06/14/17 at 1:55 p.m., S3MedRecords indicated she interpreted the by-laws to mean that privileges had to be included at reappointment only if changes were made. She confirmed that S6MedDir recommended himself at the time of reappointment.

S9MD
Review of the credentialing file for S9MD revealed the delineation of privileges for Family Practice Privileges and Internal Medicine Privileges were requested and approved on 07/13/11. There was no documented evidence of a delineation of privileges for the current approval period of 05/11/16 to 05/11/18.

S10MD
Review of the credentialing file for S10MD revealed the delineation of privileges for Family Practice Privileges and Internal Medicine Privileges were requested and approved on 07/13/11. There was no documented evidence of a delineation of privileges for the current approval period of 05/11/16 to 05/11/18.

In an interview on 10:20 a.m., S3MedRecords confirmed there was no request or approval of specific privileges at reappointment.

25065

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to develop a system/policy for the RN to supervise the MHT's documentation of the observation of patients for 5 (#2, #3, #4, #6, #7) of 10 (#1 - #10) patient records reviewed for MHT patient observation records from a total of 17 sampled patients.
2) Failing to ensure the RN accurately assessed the patient's nutrition as evidenced by failure to ensure the screening tool was completely documented for 3 (#3, #5, #6) of 10 (#1 - #10) patient records reviewed for nutritional screening by the RN from a total of 17 sampled patients.
3) Failing to ensure the speech therapist's recommendation to a patient's care plan was implemented for 1 (#16) of 1 patient record reviewed for implementation of the speech therapy treatment plan from a total of 17 sampled patients.
Findings:

1) Failing to develop a system/policy for the RN to supervise the MHT's documentation of the observation of patients:
Review of the policy titled "15 Minute Check Sheet", presented as a current policy by S2ADON, revealed that a designated MHT will note and document on the rounds sheet the location of patients every 15 minutes. Any out of the usual occurrences will be brought to the attention of the charge nurse. Further review revealed no documented evidence that the policy addressed the RN's responsibility to assure that documentation by the MHT was accurate and complete.

Review of the policy titled "Levels of Patient Observation", presented as a current policy by S1ADON, revealed that the charge RN, in conjunction with staff providing direct patient care, is responsible for assessing the observation status of all patients. Staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks.


Patient #2
Review of Patient #2's "Admission Orders", dated 06/09/17, revealed orders for special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #2's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the ordered special precautions (patient is on fall precautions) on 06/09/17 and 06/10/17. Further review revealed on 06/11/17 and 06/12/17 both the observation level and special precautions (fall) were left blank.

Patient #3
Review of Patient #3's "Admission Orders" revealed special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #3's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the date, level of observation, and fall precautions on the record initiated the day of admit (06/08/17). Further review revealed the record did not include fall precautions on 06/09/17 and 06/10/17. Further review revealed the record didn't include the level of observation and fall precautions on 06/11/17 and 06/12/17.

Patient #4
Review of Patient #4's "Admission Orders" dated 06/08/17 revealed special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #4's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the date, level of observation, and fall precautions on the record initiated the day of admit (06/08/17). Further review revealed the record did not include fall precautions on 06/09/17, 06/10/17, 06/11/17, and 06/12/17.


Patient #6
Review of Patient #6's "Admission Orders", dated 05/31/17, revealed orders for special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #6's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of the ordered special precautions (patient is on fall precautions) on 06/01/17, 06/02/17, 06/03/17, 06/04/17, 06/05/17, 06/06/17, 06/07/17, 06/08/17, 06/09/17, and 06/10/17. Further review revealed on 05/31/17, 06/11/17, and 06/12/17 both the observation level and special precautions (fall) were left blank on Patient #6's observation records.

Patient #7
Review of Patient #7's medical record revealed orders for special precautions of Q 15 minute safety monitoring and fall precautions.

Review of Patient #7's "15 Minute Checks 8 (hour) Shift Patient Observation Record" revealed no documented evidence of fall precautions as a special precaution on 05/26/17, 05/27/17, 05/28/17, 05/29/17, 05/30/17, 05/31/17, 06/01/17, 06/02/17, 06/03/17, 06/04/17, 06/05/17, 06/06/17, 06/08/17, 06/09/17, and 06/10/17. Further review revealed no documented evidence of the level of observation and fall precautions on 06/07/17, 06/11/17, and 06/12/17.

In an interview on 06/14/17 at 1:15 p.m., S5RN indicated the MHT's observation is prepared on the night shift by a MHT for the next day. She further indicated she wasn't aware of a process or policy that required the RN to review the MHT's patient observation records for completeness and accuracy. She indicated that the nursing staff considers each patient a fall risk, so they fall precautions isn't listed on the patient's observation record.

In an interview on 06/14/17 at 1:45 p.m., S2ADON confirmed that fall precautions should be documented on the MHT's patient observation records. She confirmed that the nurse doesn't review the MHT's observation records.


2) Failing to ensure the RN accurately assessed the patient's nutrition:
Review of the policy titled "Scope of Services - Nursing", presented as a current policy by S2ADON, revealed that the RN is responsible for the nursing assessment as part of the admission procedures.

Review of the "Nutritional Screening - Inpatient", a form that is part of the RN's admission assessment, revealed 10 screening items with a point value assigned to each item. When the items' scores are added, the total score determines if the form has to be faxed to the RD to perform an assessment within 72 hours. One of the items in the list of screening items is the patient's weight and height, with an attached form that indicates the target weight ranges to determine the score to be given to this item.

Patient #3
Review of Patient #3's "Nutritional Screening - Inpatient" documented on 06/08/17 at 7:20 p.m. revealed her height was 61 inches, and there was no documented evidence of her weight. There was no means of determining a score for the item of "above/below desirable body weight" without a weight documented. Review of her medical record revealed her weight was 145 pounds. Patient #3's height and weight placed her above her ideal body weight when the chart was reviewed. This would have resulted in her scoring a "1" which would have given her a total score of "3". A score of "3" would have resulted in her form having to be faxed to the RD for a nutritional assessment. As of the review of Patient #3's medical record on 06/13/17, there was no documented evidence that a nutritional assessment had been conducted by the RD.

Patient #5
Review of Patient #5's "Nutritional Screening - Inpatient" documented on 05/26/17 at 4:00 p.m. revealed his height was 70 inches, and there was no documented evidence of his weight. There was no means of determining a score for the item of "above/below desirable body weight" without a weight documented. Further review revealed the screening tool had not been completed but a score of 1-2 (no nutritional follow-up needed) was assigned.

Patient #6
Review of Patient #6's "Nutritional Screening - Inpatient" documented on 05/31/17 at 4:50 p.m. revealed his height was 67 inches, and there was no documented evidence of his weight. There was no means of determining a score for the item of "above/below desirable body weight" without a weight documented. Further review revealed the screening tool had not been completed but a score of 1-2 (no nutritional follow-up needed) was assigned.

In an interview on 06/14/17 at 1:15 p.m., S5RN indicated the RN completes the initial nutritional screening on admit. She confirmed that a patient's nutritional screen is incomplete without a patient's height and weight. After reviewing Patient #3's nutritional screening, S5RN confirmed that Patient #3 should have scored a "1" when her weight was added to the form. She confirmed this score would have resulted in a total score of "3" which would have required the RN to fax the screening assessment to the RD for a nutritional assessment to be conducted by the RD. After review of Patient #3's medical record, S5RN confirmed that the RD had not conducted a nutritional assessment for Patient #3.

In an interview on 06/14/17 at 1:45 p.m., S2ADON indicated the nurse is supposed to include the patient's weight and height on the nutritional screening tool.

3) Failing to ensure the speech therapist's recommendation to a patient's care plan was implemented:
Review of Patient #16's medical record revealed a physician's order on 02/02/17 at 8:00 a.m. for speech therapy to evaluate for aspiration.

Review of Patient #16's "Clinical Bedside Swallowing Evaluation", documented by S16ST on 02/03/17, revealed strategies included chin down, small bites, slow rate, alternate food/liquid, and liquids from a cup with no straw. Additional recommendation from S16ST revealed dysphagia therapy.

Review of Patient #16's nursing documentation revealed no documented evidence of implementation of ST's care plan by the nursing staff for dysphagia therapy as described above.

In an interview on 06/14/17 at 1:10 p.m., S2ADON indicated she could find no documented evidence in Patient #16's medical record of the nursing staff implementing S16ST's recommendations for dysphagia.







30364




30984

Based on record review and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient in accordance with the patient's needs. This deficient practice is evidenced by the RN not assigning MHTs individual patients to make 15 minute observations of on the unit resulting in 2 patients (#3, #4) not being observed for 2 or more hours.
Findings:

Review of the facility policy titled 15 Minute Check Sheet revealed in part:
A designated MHT will note and document on the rounds sheet the location of patients every fifteen minutes.
1) A every 15 minute sheet will be initiated by each night shift.
2) An MHT will be assigned the responsibility of observing and documenting patient rounds every 15 minutes.

Review of Patient #3's medical record revealed she was admitted on 06/08/17 at 7:20 p.m. with diagnoses which included Dementia with behavioral disturbances. Further review revealed she was ordered to be on 15 minute safety observations and fall precautions.

Review of Patient #4's medical record revealed she was admitted 06/08/17 at 8:50 p.m. with diagnoses which included Bipolar 1 disorder with psychotic behavior. Further review revealed she was ordered to be on 15 minute safety observations and fall precautions.

An observation was made with S2ADON on 06/14/17 beginning at 10:30 a.m. of recorded video footage of the patients' hallway in the hospital. The time period observed was on 06/11/17 from 1:00 a.m. until 3:00 a.m. Observation revealed no staff member observed the patients in Room "A" (Patients #3 and #4) from 1:00 a.m. until 3:00 a.m. (2 hours).

Review of documents in Patient #3's and Patient #4's medical records titled 15 Minute Checks Patient Observation Records revealed S22MHT had initialed he had observed the 2 patients every 15 minutes from midnight to 3:45 a.m. on 06/11/17.

In an interview on 06/14/17 at 11:10 a.m. with S2ADON, she verified no staff member had made any observations on Patient #3 or #4 for 2 or more hours on 06/11/17. S2ADON said nobody checking on the 2 patients in Room "A" for 2 hours was unacceptable. She said somebody should have checked on them every 15 minutes. S2ADON verified S22MHT documenting that he checked on the 2 patients every 15 minutes was false documentation. S2ADON also verified the night charge nurse did not make specific assignments for the MHTs. She said every staff was responsible for every patient.

In an interview on 06/14/17 at 12:54 p.m. with S5RN, she said she worked on 06/10/17 at 6:00 p.m. through 6:15 a.m. on 06/11/17 and was in charge. She said the assignments were made by her because she was the charge nurse. She said she did not assign a certain patient to a certain MHT. She said the technicians divided the patients themselves unless there was a patient that required more frequent observations than every 15 minutes. S5RN verified Patient #3 and Patient #4 should have been monitored every 15 minutes and 2 hours out of sight was unacceptable.

In an interview on 06/14/17 at 1:45 p.m. with S22MHT, he said he was working from 6:00 p.m. on 06/10/17 and left at 6:00 a.m. on 06/11/17. S22MHT said he was sitting with a patient in Room "B" who was a fall risk and combative. He said at other facilities he worked he had a patient assignment but here all of the MHTs were responsible for all of the patients. S22MHT said that was not a good system because nobody was responsible for a particular patient. S22MHT said he was wrong and he was sorry but he did not observe Patient #3 or Patient #4 from 6:00 p.m. until 3:45 a.m. but he documented that he had observed them every 15 minutes. He said he only observed the patients in Room "B" the night of 06/10/17. He said he could not assure the 2 patients in Room "A" were safe. He also said both patients were also fall risks. S22MHT said nobody watches the patients as ordered. He said there was disorganization on the unit and they needed structure. S22MHT said he filled out the observation sheets on other MHT's patients although he did not observe them and the MHTs did not communicate about the patients status every 15 minutes. He said S5RN knew he was not checking on the patients in Room "A".

Based on record review and interview, the hospital failed to ensure the organization of the medical record services was appropriate to the scope and the complexity of services provided as evidenced by failing to ensure the medical records department was under the supervision of a qualified individual.
Findings:

Review of S3MedRecords' personnel file revealed she had no degree or certification in health information management.

In an interview on 06/14/17 at 8:38 a.m. with S3MedRecords, she said she was the director of medical records for the hospital. She said she did not have any certifications or degree in health information management.

In an interview on 06/14/17 at 8:41 a.m. with S1Adm, he said he did not currently have a qualified medical records director contracted to be responsible for the medical records on a full time, part time or consulting basis.

30364



Based on observation and interview the hospital failed to ensure all medical records were properly stored in secure locations where they were protected from water damage in the event that the sprinkler system in the storage room was activated.

Findings:

Observation on 06/14/17 at 8:30 a.m. of a storage room for closed paper medical records revealed the room contained sprinklers in the ceiling. Further review revealed 60 cardboard boxes containing paper medical records that would not be protected from destruction or damage if the sprinkler system was activated.

In an interview on 06/14/17 at 8:34 a.m. with S3MedRecords, she verified the boxes in the storage room contained medical records. She said each box contained approximately 20 records. S3MedRecords verified the boxes should have been covered by a waterproof covering but were not.

25065

Based on record reviews and interview, the hospital failed to ensure all patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided as evidenced by failure to have physician signatures dated and timed by the physician for 6 (#3, #4, #5, #6, #7, #8) of 10 (#1 - #10) patient records reviewed for dating and timing of signatures from a total sample of 17 patients.
Findings:

Review of the "Rules And Regulations For The Professional Medical Staff Performance Improvement", presented as the current medical staff rules and regulations by S3MedRecords, revealed that all clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.

Patient #3
Review of Patient #3's Admission/Consultation Note revealed it had been signed by S9MD but the authentication had not been dated or timed.

Patient #4
Review of Patient #4's Medication Reconciliation /MD Order dated 06/08/17 revealed it had been signed and dated by the physician but the authentication had not been timed.

Patient #5
Review of Patient #5's Admission/Consultation Note revealed it had been signed by S9MD but the authentication had not been dated or timed.

Patient #6
Review of Patient #6's H&P (History and Physical), dictated on 06/01/17, revealed S10MD had authenticated the H&P, but had not dated or timed the authentication as of 06/13/17 (date of review).

Patient #7
Review of Patient #7's "Admission/Consultation Note" dated 05/27/17 and signed by S9MD revealed no documented evidence of the date and time that S9MD signed the note.

Patient #8
Review of the medical record for Patient #8 revealed the "Admission/Consultation Note" dated 05/24/17 revealed S9MD had authenticated the H&P but had not dated or timed the authentication as of 06/13/17 (date of review).

In an interview on 06/15/17 at 7:30 a.m., S3MedRecords confirmed she considered the H&P completed if it was signed by the physician. S3MedRecords confirmed the above findings and stated there was no current monitoring system in placed that addressed dating and timing of signatures.



30364





30984

25065

Based on record review and interview, the hospital failed to ensure a medical history and physical examination was completed and documented no more than 30 days before or 24 hours after admission and placed in the patient's medical record within 24 hours after admission as evidenced by failure to have the patient's medical history and physical examination in the chart within 24 hours after admission for 3 (#4, #7, #8) of 10 (#1 - #10) patient records reviewed for history and physical examination documentation from a total sample of 17 patients.
Findings:

Review of the "Rules And Regulations For The Professional Medical Staff Performance Improvement", presented as the current medical staff rules and regulations by S3MedRecords, revealed that a complete admission history and physical examination shall be recorded by an MD or Nurse Practitioner within 24 hours of the patient's admission. Further review revealed no documented evidence that the rules and regulations addressed that the medical history and physical examination had to be in the patient's medical record within 24 hours after admission.

Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 06/08/17 at 1:28 p.m. Review of the "Admission/Consultation Note" dated 06/09/17 by S9MD (not signed) revealed the examination was conducted on 06/09/17, the note was dictated on 06/09/17 at 10:36 a.m., and the note was transcribed on 06/10/17 (over 24 hours after admission) with no time of transcription indicated.

Patient #7
Review of Patient #7's "Admission/Consultation Note" dated 05/27/17 and signed by S9MD, with no documented evidence of the date and time S9MD signed the note, revealed the examination was conducted on 05/27/17, the note was dictated on 05/27/17, and the note was transcribed on 05/28/17 (48 hours after Patient #7 was admitted on 05/26/17).

Patient #8
Review of the medical record for Patient #8 revealed the patient was admitted to the hospital on 05/23/17 at 12:25 p.m. Review of the "Admission/Consultation Note" dated 05/24/17 and signed by S9MD, with no documented evidence of the date and time S9MD signed the note, revealed the examination was conducted on 05/24/17, the note was dictated on 05/24/17, and the note was transcribed on 05/27/17 (96 hours after Patient #8 was admitted on 05/23/17).

In an interview on 06/15/17 at 7:30 a.m., S3MedRecords reviewed the above "Admission/Consultation Notes" and confirmed this was the patient's history and physical. S3MedRecords confirmed the above patients' history and physicals were not placed on the patients' records within 24 hours of admission. S3MedRecords stated the hospital used a contracted dictation service and she was unable to explain why the H&Ps were not transcribed within 24 hours of admission. S3MedRecords confirmed there was no current monitoring system in place to review medical records for dating and timing of signatures or entries in the medical record.

25065


Based on record reviews and interview, the hospital failed to ensure each patient record had a properly executed informed consent as evidenced by failure to have a properly executed "Informed Consent For Psychotropic Medications" for 6 (#1, #2, #3, #4, #5, #7) of 10 (#1 - #10) patient records reviewed for completion of consents from a total sample of 17 patients.
Findings:

Review of the policy titled "Consent Form", presented as a current policy by S2ADON, revealed that as part of the routine admission procedure, each patient will be asked to sign the authorization/consent form, and a staff member will sign as a witness. Further review revealed no documented evidence that the policy addressed completion of the "Informed Consent For Psychotropic Medications".

Patient #1
Review of Patient #1's "Medication Reconciliation/MD Order" revealed she was prescribed at admit Olanzapine (anti-psychotic). Review of her "Informed Consent For Psychotropic Medications", witnessed by S4RN on 06/09/17 at 12:00 p.m. and a note of "pt. (patient) was unable to sign", revealed no documented evidence of a check mark next to "Anti-Psychotics" and no medication written in the space provided.

Patient #2
Review of Patient #2's "Medication Reconciliation/MD Order" revealed he was prescribed at admit Risperidone (anti-psychotic), Xanax (Anti-anxiety) and Zoloft (anti-depressant). Review of his "Informed Consent For Psychotropic Medications", witnessed by S4RN on 06/09/17 (not timed), revealed a note of "pt. (patient) unable to sign". Further review revealed no documented evidence of a check mark next to "Anti-Depressants", "Anti-Anxiety", and "Anti-Psychotics" and no medications had been written in the spaces provided with each drug class.

Patient #3
Review of Patient #3's "Medication Reconciliation/MD Order" revealed she was prescribed at admit Risperidone (anti-psychotic) and Seroquel (anti-psychotic). Review of her "Informed Consent For Psychotropic Medications", witnessed by S4RN on 05/26/17 at 4:00 p.m. and a note of "nca (non-contested admission)", revealed no documented evidence of a check mark next to "Anti-Psychotics" and no medications written in the space provided.

Patient #4
Review of Patient #4's "Medication Reconciliation/MD Order" revealed the patient was prescribed at admit Seroquel (anti-psychotic). Review of the "Informed Consent For Psychotropic Medications", witnessed by S4RN on 06/08/17 at 8:50 p.m. revealed no documented evidence of a check mark next to "Anti-Psychotics" and no medications written in the space provided.

Patient #5
Review of Patient #5's "Medication Reconciliation/MD Order" revealed he was prescribed at admit Risperidone (anti-psychotic) and Prozac (anti-depressant). Review of his "Informed Consent For Psychotropic Medications", witnessed by S4RN on 06/08/17 at 7:20 p.m. and a note of "pt. (patient) unable to sign", revealed no documented evidence of a check mark next to "Anti-Depressants" and "Anti-Psychotics" and no medication written in the space provided.

Patient #7
Review of Patient #7's "Medication Reconciliation/MD Order" revealed she was prescribed at admit Duloxetime (anti-depressant). Review of her "Informed Consent For Psychotropic Medications", witnessed by S4RN on 05/26/17 at 9:00 p.m. and a note of "pt. (patient) unable to sign", revealed "Anti-Depressants" was checked with no documented evidence of the name of the medication prescribed.

In an interview on 06/13/17 at 10:26 a.m., S2ADON indicated the consent for psychotropic medications should be completed for medications the patient is prescribed upon admit and for those medications added to the regimen during the patient's hospital stay.

In an interview on 06/14/17 at 1:15 p.m., S5RN indicated the "Informed Consent For Psychotropic Medications" should be filled out by the nurse with the type of psychotropic medication and the name of the specific medication prescribed before the patient signs the consent.






30364




30984

Based on record review and interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by the Director of Radiology (S9MD), appointed by the Governing Body, was not a radiologist.
Findings:

On 06/13/17 at 1:00 p.m., S1Adm provided a list of physician directors that indicated S9MD was the Director of Radiology. S1Adm also provided Governing Board Meeting minutes dated 01/11/17 that revealed S9MD was appointed as Director of Radiological Services.

Review of the credentialing file for S9MD revealed the physician was board certified in Family Practice. The credentialing file revealed S9MD had approved privileges in family practice and internal medicine. There was no documented evidence that S9MD had any experience or qualifications in radiology.

In an interview on 06/14/17 at 9:58 a.m., S1Adm confirmed S9MD was a family practice physician and confirmed S9MD had been appointed as Director of Radiology by the Governing Board. S1Adm confirmed S9MD did not meet the qualifications of the Director of Radiology.

Based on record review and interview, the hospital failed to ensure the UR (Utilization Review) committee consisted of 2 or more physicians who were not professionally involved in the care of the patients whose cases were being reviewed by the UR committee.
Findings:

Review of the UR committee member list, presented as current by S2ADON, revealed S6MedDir, S9MD, and S10MD were the physician members of the UR committee.

In an interview on 06/14/17 at 3:40 p.m. with S3MedRecords, she confirmed S6MedDir, S9MD, and S10MD were the only physician members of the UR committee. S3MedRecords reported S6MedDir, S9MD, and S10MD were performing the patient case reviews for UR. She confirmed all 3 of the above referenced physicians were directly involved in the care/management of the patients whose cases were reviewed by the hospital's UR committee.

Based on record reivew and interview, the hospital failed to ensure the person designated as infection control officer was qualified through education, training, experience, or certification as evidenced by appointment of S2ADON (acting Director of Nursing) who was not qualified through education, training, experience, or certification as infection control officer.
Findings:

Review of S2ADON's personnel file revealed no documented evidence of education, training, experience, or certification in Infection Control.

In an interview on 06/15/17 at 11:50 a.m. with S2ADON, she confirmed she was serving as the hospital's appointed infection control officer. S2ADON also confirmed she had not received education, training, or certification in Infection Control. S2ADON reported she had not served as an infection control officer in the past and had no prior experience in infection control other than the basic infection control training all nurses received as part of their job training.

25065

Based on record reviews and interviews, the hospital failed to ensure discharge planning included an evaluation of the patient's functional status and cognitive ability, the type of post-hospital care the patient may require and whether such care requires the services of health care professionals or facilities, the availability of the post-hospital health care services to the patient, and the availability and capability of family and/or friends to provide follow-up care in the home as evidenced by failure to have such evaluations documented in 4 of 4 (#7, #8, #10, #11) patient records reviewed for discharge planning from a total sample of 17 patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S2ADON, revealed the case manager will be the primary team member responsible for coordinating discharge planning. The social worker will evaluate potential discharge problems and will make recommendations for discharge planning in the psychosocial assessment within 72 hours of admission. The social worker will notify case management of recommendations and potential discharge problems. The case manager, along with other members of the treatment team, will discuss and document discharge plans with the patient and family prior to discharge. The purpose of the contact is to finalize living arrangements and aftercare plans, review the patient's medication regimen, and educate the patient and family on the disease process and what steps to take in the event of a crisis. There was no documented evidence that the policy addressed the required communication when the patient was returning to a nursing home, such as whether the nursing home was willing and able to accept the patient upon discharge and provide the needed services.

Patient #7
Review of Patient #7's medical record revealed a multi-disciplinary note documented by S15CM dated 06/13/17 at 9:40 a.m. stating that a discharge packet was faxed to the nursing home where Patient #7 was a resident prior to hospitalization and notification that she was being discharged on 06/13/17. There was a multi-disciplinary note dated 06/13/17 at 11:24 a.m. by S14LCSW that read that S14LCSW spoke with Patient #7's son on 06/06/17 about his mother's tentative discharge within the next 7 - 10 days. There was no documented evidence of communication by S15CM or S14LCSW with the nursing home to determine whether Patient #7 would be accepted back after discharge.

Review of Patient #7's "Treatment Team Plan Review" for 05/29/17, 06/05/17, and 06/12/17 revealed no documented evidence that the sections related to discharge planning and estimated date of discharge were completed.


Patient #8
Review of the medical record for Patient #8 revealed the patient was admitted to the hospital on 05/23/17 and discharged on 06/13/17. Review of the record revealed the patient had been admitted from a nursing home. Further review revealed the preliminary discharge plan for Patient #8 was for the patient to return to the nursing home where the patient had resided prior to hospitalization. Additional review of Patient #8's medical record revealed no documented evidence of communication by S15CM or S14LCSW with the nursing home regarding Patient #8's return after his discharge from the hospital, until the day of discharge when a packet was faxed to the nursing home. Review of Patient #8's entire medical record revealed no documented evidence of ongoing discharge planning/preparation for Patient #8's discharge.


Patient #10
Review of Patient #10's medical record revealed a multi-disciplinary note documented by S15CM dated 05/29/17 at 1:12 p.m. stating that a discharge packet was faxed to the nursing home where Patient #10 was a resident prior to hospitalization and notification that he was being discharged on 05/31/17. There was a multi-disciplinary note dated 05/04/17 at 12:32 p.m. by S14LCSW that read that S14LCSW left a voice mail for the patient's daughter explaining the tentative discharge was within the next 7 - 10 days. There was no documented evidence of communication by S15CM or S14LCSW with the nursing home to determine whether Patient #10 would be accepted back after discharge.


Patient #11
Review of Patient #11's Psychosocial Assessment, dated 03/06/17 at 2:13 p.m., revealed the patient had been admitted from a nursing home on 03/03/17. Further review revealed the preliminary discharge plan for Patient #11 was for the patient to return to the nursing home where he had resided prior to hospitalization. Additional review of Patient #11's medical record revealed no documented evidence of communication by S15CM or S14LCSW with the nursing home regarding Patient #11's return after his discharge from the hospital, until the day of discharge when a packet was faxed to the nursing home. Review of Patient #11's entire medical record revealed no documented evidence of ongoing discharge planning/preparation for Patient #11's discharge.

In an interview on 06/14/17 at 4:00 p.m., S14LCSW indicated she was responsible for discharge planning, but the discharge planner was S15CM. S14LCSW indicated the hospital doesn't have a discharge planning form. She further indicated the team discusses discharge planning at treatment team meetings. She confirmed the patient records don't include communication with the nursing home when the patient was admitted as a resident of a nursing home.

In an interview on 06/15/17 at 7:55 a.m., S15CM indicated when it's time for discharge, she enters a note in the medical record that includes where the location where the patient is being discharged and the appointments that are scheduled. She confirmed she doesn't document anything related to an evaluation of the patient to determine if they're able to return to the location from which they resided prior to hospitalization, whether they can care for themselves, and if not, whether there is someone capable and willing to provide the required care. S15CM indicated the hospital didn't have a system in place to evaluate a patient's discharge needs.



30984

25065

Based on record reviews and interview, the hospital failed to ensure patients and their family members or interested persons were counseled to prepare them for post-hospital care as evidenced by failing to include a list of all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications for 4 of 4 (#7, #8, #10, #11) patient records reviewed for discharge medication changes from a total sample of 17 patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S2ADON, revealed the case manager, along with other members of the treatment team, will discuss and document discharge plans with the patient and family prior to discharge. The purpose of the contact is to review the patient's medication regimen and educate the patient and family on the disease process and what steps to take in the event of a crisis. There was no documented evidence that the policy addressed that the medication list would include a clear indication of changes from the patient's pre-admission medications and the required communication when the patient was returning to a nursing home.

Patient #7
Review of Patient #7's pre-hospital medication list revealed she was taking Metformin 1000 mg (milligrams) orally twice a day, and she was prescribed Metformin 500 mg orally twice a day at discharge. There was no documented evidence that the change in dosage was clearly addressed in the documentation sent to the nursing home.

Patient #8
Review of Patient #8's pre-hospital medication list revealed she was taking Xanax 0.25 mg orally twice a day, and she was prescribed Xanax 0.25 mg orally three times a day at discharge. There was no documented evidence that the change in dosage was clearly addressed in the documentation sent to the nursing home.

Patient #10
Review of Patient #10's pre-hospital and discharge medications revealed the following changes: Lantunoprost 0.003% at admit and 0.005% at discharge; Duloxetine, Namenda 5 mg orally daily and 10 mg orally at bedtime, Aricept, Zoloft, Ativan, Seroquel, and Neurontin were taken pre-hospitalization but not ordered at discharge; Lantus 20 units at bedtime prior to hospitalization and discharged on 10 units daily. There was no documented evidence that the change in dosages were clearly addressed in the documentation sent to the nursing home.

Patient #11
Review of Patient #11's pre-hospital and discharge medications revealed the following changes: Xanax 0.5 mg orally Q HS at 10:00 p.m. was added, Zoloft was increased from 25 mg orally at bedtime to 50 mg orally Q HS, Trilafon 2 mg orally Q HS was added, and Seroquel 25 mg po twice a day was discontinued. There was no documented evidence that the change in dosage/change in medications were clearly addressed in the documentation sent to the nursing home.

In an interview on 06/14/17 at 1:45 p.m., S2ADON confirmed the medical records of Patients #7, #8, #10, and #11 did not have documentation of changes in the medications ordered at discharge from what the patient was taking prior to being hospitalized.





30984

Based on record review and interview, the hospital failed to ensure outpatient services were organized and integrated with inpatient services as evidenced by failing to ensure the hospital's policy provided for outpatients at the offsite campus who required inpatient hospitalization to be sent to the main campus if the main campus had beds available.
Findings:

Review of the hospital policy titled "Suicidal/Homicidal Patient", presented as the current outpatient policy by S1Adm, revealed the policy was revised August 2016. Further review revealed the following:
1) An assessment of the patient, who is experiencing psychiatric decompensation, will be performed by the clinical staff, in order to determine whether the patient is in need of inpatient hospitalization.
2) The patient is to be immediately placed on one-to-one observation with a staff member remaining with the patient at all times.
3) The attending physician is notified of the patient's status and necessary orders are obtained.
4) If the patient is unwilling to seek voluntary admission to inpatient treatment, staff is to contact 911 for emergency assistance or accompany the patient to the nearest emergency room.
5) The patient's information is sent to the Intake Department so that transfer of the patient to an inpatient unit can be arranged according to intake processes and procedures. The Intake Department will attempt to transfer the patient to the main campus of the hospital first, dependent upon availability of beds at the time of transfer. Further review revealed the policy had the same verbiage as the policy that was presented during the follow-up survey conducted 07/26/16 that was cited as deficient practice.
There was no documented evidence that the policy ensured the treatment for patients exhibiting emergency behaviors located at their offsite campus was the same treatment that was provided at their main campus. The policy allowed patients to be treated one way when a qualified practitioner is onsite (practitioner will evaluate and PEC if needed), but when no practitioner is onsite, the staff will call 911 and have the patient transported to the emergency room.

In an interview on 06/14/17 at 4:35 p.m., S1Adm presented the revised outpatient policy related to outpatients who decompensate. He indicated the policy was written as it was, because sometimes the psychiatrist is out of the area seeing patients at one of their other facilities. He further indicated it would be better to call 911 to have the suicidal/homicidal patient transported to an emergency room to be PEC'd rather than to wait for the psychiatrist to arrive to evaluate the patient. When informed that the policy didn't provide for outpatients to be treated the same as inpatients (evaluated and PEC'd if necessary when decompensating), S1Adm had no explanation to offer.

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

1) Failing to ensure the scope of rehabilitation services offered by the hospital was defined in written policies and procedures approved by the Medical Staff as evidenced by failure to have policies and procedures developed for the rehabilitation services provided by the hospital (see findings in tag A1124).

2) Failing to designate a director of rehabilitation services who had the knowledge, experience, and capabilities to properly supervise and administer the services as evidenced by having no individual designated as the director of rehabilitation services (see findings in tag A1125).

3) Failing to ensure physical therapy and speech therapy-language pathology services were provided by qualified therapists/pathologists as evidenced by failure to have documented evidence of evaluation of skills/competency for 3 (S16ST, S17PT, S18PT) of 3 rehabilitation staff personnel files reviewed for competency (see findings in tag A1126).

Based on record review and interview, the hospital failed to ensure the scope of rehabilitation services offered by the hospital was defined in written policies and procedures approved by the Medical Staff as evidenced by failure to have policies and procedures developed for the rehabilitation services provided by the hospital.
Findings:

Review of the "Performance Improvement PLan 2017", presented as the current plan by S8HR, revealed no documented evidence that rehabilitation services was included in the plan other than a review of 2 contracts per quarter.

In an interview on 06/14/17 at 1:55 p.m., S1Adm indicated the hospital had no policies and procedures developed that were approved by the Medical Staff for the rehabilitation services provided by the hospital's contract staff. He indicated the hospital provides physical therapy and speech and language pathology services.

Based on interview, the hospital failed to designate a director of rehabilitation services who had the knowledge, experience, and capabilities to properly supervise and administer the services as evidenced by having no individual designated as the director of rehabilitation services.
Findings:

In an interview on 06/14/17 at 9:44 a.m., S1Adm indicated the hospital doesn't have anyone designated as Director of Rehabilitation Services. He confirmed that physical therapy and speech and language pathology services are provided by the hospital through contract staff.

Based on record reviews and interview, the hospital failed to ensure physical therapy and speech therapy-language pathology services were provided by qualified therapists/pathologists as evidenced by failure to have documented evidence of evaluation of skills/competency for 3 (S16ST, S17PT, S18PT) of 3 rehabilitation staff personnel files reviewed for competency.
Findings:

Review of the "2017 Staff Development Plan", presented as the current plan by S8HR, revealed that all staff will demonstrate the appropriate knowledge and skills necessary to provide quality care/service appropriate to any age/disability related needs of the patients served. Employees with direct patient care responsibilities will obtain and maintain current certification in EDGE. Employees must attend certification classes which are routinely held on-site. Upon completion of the 90 day evaluation period, the supervisor shall evaluate the employee's skill level and make a determination of the employee's competency level. Review of the plan revealed no documented evidence that the plan addressed the competency, evaluation, and certification related to the contract direct care staff.

S16ST
Review of S16ST's personnel file revealed no documented evidence of an evaluation of competency in performing specific job skills.

S17PT
Review of S17PT's personnel file revealed no documented evidence of an evaluation of competency in performing specific job skills.

S18PT
Review of S18PT's personnel file revealed she was evaluated for competency by a peer from the contract company for which she worked. There was no documented evidence of any evaluation by a hospital staff member related to the services provided to patients.

In an interview on 06/15/17 at 9:45 a.m., S1Adm was informed of the above findings related to the personnel file reviews of S16ST, S17PT, and S18PT. He offered no explanation for not having documented evidence of competency evaluations.

Based on record reviews and interview, the hospital failed to ensure rehabilitation services were provided in accordance with requirements of the certification regulations as evidenced by failure of the therapy plan of care to include the type of services to be provided and the duration of service for 3 (#13, #14, #15) of 3 rehabilitation patient records reviewed from a total sample of 17 patients.
Findings:

No policies and procedures were presented by the hospital related to rehabilitation services.

Patient #13
Review of Patient #13's medical record revealed a physician's order dated 03/28/17 at 1:50 p.m. for PT to evaluate strengthening and mobility.

Review of Patient #13's "Physical Therapy Initial Assessment Form" documented by S17PT on 03/29/17 revealed the frequency was 3 times a week. There was no documented evidence of the duration of treatment and the therapeutic treatment to be provided.

Patient #14
Review of Patient #14's medical record revealed a physician's order on 02/08/17 at 9:15 a.m. for PT to evaluate gait training and analysis for walking aids.

Review of Patient #14's "Physician Progress Notes" revealed documentation by S17PT on 02/09/17 (no time documented) that PT was to see patient 3 times a week for gait training and strengthening. There was no documented evidence of the duration of services.

Patient #15
Review of Patient #15's physician's orders revealed an order on 02/15/17 at 7:50 a.m. for PT.

Review of Patient #15's "Physician Progress Notes" revealed documentation by S18PT on 02/16/17 that PT was to see the patient 3 times a week for therapeutic exercises, neuro re-education, therapeutic activity, and manual therapy/soft tissue massage to cervical area to decrease pain. There was no documented evidence of the duration of services.

In an interview on 06/14/17 at 1:55 p.m., S1Adm indicated the hospital had no policies and procedures developed that were approved by the Medical Staff for the rehabilitation services provided by the hospital's contract staff.

In a telephone interview on 06/15/17 at 11:55 a.m., S17PT indicated the duration is usually based on day-to-day and week-to-week depending on the patient's length of stay, because the patients don't usually stay more than a couple of weeks. She further indicated the PT or PT assistant who follows her initial assessment visit know what treatment to provide based on the goals established. S17PT confirmed that the PTs were not including the duration in the patient's plan of care.

Based on observations, record reviews and interviews, the hospital failed to meet the Condition of Participation specified in the following:

1. 482.13 (Patient Rights)
Failing to ensure staff conducted safety observations on psychiatric patients every15 minutes as ordered by the physician for 1 patient room containing 2 (#3, #4) patients out of a total of 3 rooms containing 6 patients (#2, #3, #4, #R2, #R3, #R4) visible on the hospital provided video footage (see findings tag A-0144); and

2. 482.56 (Rehabilitation Services)
A) Failing to ensure the scope of rehabilitation services offered by the hospital was defined in written policies and procedures approved by the Medical Staff as evidenced by failure to have policies and procedures developed for the rehabilitation services provided by the hospital (see findings in tag A1124).

B) Failing to designate a director of rehabilitation services who had the knowledge, experience, and capabilities to properly supervise and administer the services as evidenced by having no individual designated as the director of rehabilitation services (see findings in tag A1125).

C) Failing to ensure physical therapy and speech therapy-language pathology services were provided by qualified therapists/pathologists as evidenced by failure to have documented evidence of evaluation of skills/competency for 3 (S16ST, S17PT, S18PT) of 3 rehabilitation staff personnel files reviewed for competency (see findings in tag A1126).

25065

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that described attitudes and behaviors as evidenced by failure to have attitudes and behaviors described by the practitioner for 3 of 3 (#3, #4, #7) current sampled patient records reviewed for documentation of attitudes and behaviors in the psychiatric evaluation from a total sample of 17 patients.
Findings:

Review of the hospital policy titled, PC-401: Psychiatric Evaluation revealed in part the following: A psychiatric evaluation completed by the psychiatrist or Psychiatric Nurse Practitioner includes the following information: G. Mental status: attitude. There was no documented evidence in the policy that directed the practitioner to describe the patient's attitudes and behaviors.

Patient #3
Review of Patient #3's psychiatric evaluation conducted by S7NP on 06/09/17 revealed "Attitude/Behavior" was documented as "apathetic." There was no documented evidence of a description of Patient #3's behaviors.

Patient #4
Review of Patient #4's psychiatric evaluation conducted by S7NP dated 06/09/17 revealed "Attitude/Behavior" was documented as "cooperative." There was no documented evidence of a description of Patient #4"s behaviors.

Patient #7
Review of Patient #7's psychiatric evaluation conducted on 05/26/17 revealed no documented evidence that behaviors were assessed and documented.

In an interview on 06/15/17 at 9:05 a.m., S6MedDir indicated S7NP uses the computerized version to document the psychiatric evaluation which doesn't include descriptions of attitudes and behaviors. He confirmed that attitudes and behaviors should be described.

25065

Based on record reviews and interview, the hospital failed to ensure each patient received a psychiatric evaluation that estimated intellectual functioning, memory functioning, and orientation as evidenced by failure to include supportive information related to how intellectual and memory functioning was evaluated for 3 of 3 (#3, #4, #7) current sampled patient records reviewed for intellectual and memory functioning and orientation in the psychiatric evaluation from a total sample of 17 patients.
Findings:

Review of the hospital policy titled, PC-401: Psychiatric Evaluation revealed in part the following: A psychiatric evaluation completed by the psychiatrist or Psychiatric Nurse Practitioner includes the following information: G. Mental status: Memory. There was no documented evidence in the policy that directed the practitioner to include supportive information related to how intellectual and memory function was evaluated.

Patient #3
Review of Patient #3's psychiatric evaluation conducted and documented by S7NP on 06/09/17 revealed recent and remote memory were impaired. There was no documented evidence of the means used to determine memory functioning. Further review revealed no documented evidence of an assessment of intellectual functioning.

Patient #4
Review of Patient #4's psychiatric evaluation conducted by S7NP dated 06/09/17 revealed recent and remote memory was intact. There was no documented evidence of the means used to determine memory functioning. Further review revealed no documented evidence of an assessment of intellectual functioning

Patient #7
Review of Patient #7's psychiatric evaluation conducted on 05/26/17 revealed her recent and remote memory were intact, her immediate recall was intact, and her intelligence was average. There was no documented evidence of the means used to determine the intellectual and memory functioning of Patient #7.

In an interview on 06/15/17 at 9:05 a.m., S6MedDir indicated S7NP uses the computerized version to document the psychiatric evaluation which doesn't include the measurement used to determine memory and intellectual functioning. He offered no explanation for the printed version of the psychiatric evaluation having check boxes for documenting intellectual and memory functioning with no means of measurement to be used to assess the patient's functioning.

Based on interview, the hospital failed to have an available psychologist to provide psychological services to meet the needs of the patients as evidenced by S3MedRecords reporting that S13MP's credentials had expired, and S12Phd was not currently credentialed by the Governing Board.
Findings:

In an interview on 06/14/17 at 10:45 a.m., S3MedRecords indicated S13MP did not complete a reappointment application, so her appointment had expired. She further indicated S12Phd's appointment had not been approved by the Medical Staff and Governing Board. She confirmed that they did not currently have a credentialed psychologist to provide services.

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Based on record reviews and interview, the hospital failed to ensure individualized therapeutic activities were provided to meet the needs and interests of patients and were directed toward restoring and maintaining optimal levels of physical and psychological functioning as evidenced by failure to provide individualized therapeutic activities to meet the needs of the patient and failing to include therapeutic activities in the patient's treatment plan for 3 of 3 (#2, #3, #4) sampled current patient records reviewed for activity therapy from a total sample of 17 patients.

Findings:

Review of the hospital policy titled, PC-109: Activity Therapy, effective date of 07/10/12 revealed the following:
The objective of the Therapeutic Activity Program is to restore and maintain optimal levels of physical and psychosocial functioning based on the patient's needs and interests. Therapeutic Activity is focused upon the development and maintenance of adaptive skills that will improve the patient's functioning and provide the patient with individualized opportunities to acquire knowledge, skills and attitudes with the goal for crossover to post discharge environment. Activity Groups will be structured groups provided by designated staff under the written plan and supervision of Activities Director. Activity assessments will be completed within 72 hours of admission. The assessment will be used to identify problems, set goals and implement specific treatment modalities in the patient's multidisciplinary treatment plan.

Patient #2
Review of Patient #2's medical record revealed an Admit Diagnosis of Major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance. Further review revealed the patient was assessed as gravely disabled and unable to care for self.

Review of Patient #2's Treatment Team Plan Review revealed the patient had a history of touching peers mouth and face, poor boundaries, difficult to redirect, grabbing peers, wandering, and repetitive speech.

Review of Patient #2's "Activity Assessment - Inpatient" revealed the section for the Activity Therapist's Signature was left blank, the document was timed for 10:40 (no a.m. or p.m. indicated) and no date of completion was documented. The Activity Assessment lacked a diagnosis and an education level. The patient's limitations/precautions were listed as fall risk. Further review revealed Treatment Plan Adaptation needed was answered as: Yes. The sections indicating current and past participation in crafts, literary, social activity, music, nature outings, sports and fitness, entertainment, games, and interests were marked through with a notation of "unable to assess". Additional review revealed the section on the assessment that addressed the patient's strengths, weaknesses, and barriers that affect leisure time were left blank. There was no documented evidence of a plan for activity therapy that included the frequency at which activities would be provided and the type of activities that would be provided.

On 6/13/17 at 9:30 a.m. an observation was made of Patient #2. He was observed walking to a door and repeatedly turning the handle repeating a woman's name over and over. The surveyor attempted to make eye contact and to engage the patient and he did not engage nor did he respond to the surveyor's greeting/questions.

Review of a Group Progress Note, dated 06/10/17, documented by the LPN who had conducted the Leisure Activity Group, revealed in part: Intervention: Leisure Activity to improve mood. Further review revealed Patient #2's response was documented as patient was absent during group, in room sleeping. There was no documented evidence that individualized therapeutic activities were planned to meet the specific needs of Patient #2.

Review of a Group Progress Note documented by S15CM on 06/13/17 at 12:39 p.m. revealed that Patient #2 was inattentive, intrusive, impulsive, withdrawn, with a thought content of delusional and preoccupied. The patient's response was documented as: Patient attended without participation. Pt. slept throughout leisure activity. There was no documented evidence that individualized therapeutic activities were planned to meet the needs of Patient #2.


Patient #3
Review of Patient #3's "Activity Assessment - Inpatient" conducted by S15CM on 06/09/17 at 9:00 a.m. revealed S15CM was unable to assess Patient #3's current and past participation in crafts, literary, social activity, music, nature outings, sports and fitness, entertainment, games, and interests. Further review revealed S15CM assessed her strengths, weaknesses, and barriers that affect leisure time. There was no documented evidence of a plan for activity therapy that included the frequency at which activities would be provided and the type of activities that would be provided.

Review of group progress notes documented by S15CM on 06/13/17 at 11:52 a.m. and 12:45 p.m. revealed that Patient #3 is in a catatonic state, is difficult to communicate with, is very confused, is difficult to redirect, and has no interaction with peers. There was no documented evidence that individualized therapeutic activities were planned to meet the needs of Patient #3.

In an interview on 06/15/17 at 7:55 a.m., S15CM indicated she does activities that all patients can take part in, even demented patients, such as music therapy and exercising. She further indicated she does groups on Tuesday, Thursday, and Friday. She confirmed no certified recreational therapeutic specialist is providing activity therapy on Monday, Wednesday, and weekends. She gave no explanation for Patient #3 not having an individualized therapeutic activity related to her mental ability.


Patient #4
Review of the medical record for Patient #4 revealed the patient was a 62 year old admitted to the hospital under a PEC on 06/08/17 with a diagnosis of Depression. The patient's diagnoses included Bipolar Disorder with Psychotic Behavior.

Review of the Activity Assessment dated 06/09/17, signed by S15CM revealed the patient was assessed as alert, oriented, follows 3 step commands and had no short or long term memory loss. The assessment revealed the patient was ambulatory and independent in physical activity. The assessment indicate the patient had current and past participation in the following activities: needlework, painting/drawing, arts and crafts, reading, visiting, parties, gardening, exercising, movies and radio, bingo and table games and interest in cooking and animals. There was no documented evidence of a plan for activity therapy that included the frequency at which activities would be provided and the type of activities that would be provided.

Review of the treatment plan for Patient #4 revealed no documented evidence that therapeutic activities were included in the plan.

Review of the Group Progress Notes for Patient #4 revealed the following:
06/13/17 at 10:15 a.m. - documented by S15CM: Sensory motor skills to increase group cohesion. Minimum prompts is needed for minimum participation. Patient had good range of motion. Patient was appropriate. Patient was able to follow directions accordingly with assistance. Patient continues to improve.
06/09/17 at 10:15 a.m. - documented by S15CM: Leisure activity using cognitive method to increase group cohesion. Minimum prompts is needed for minimum participation. Patient was appropriate, patient was able to follow directions accordingly. Patient stated she was feeling better and her confusion has improved.
There was no documented evidence of any other therapeutic activities provided to Patient #4.

In an interview on 06/15/17 at 7:40 a.m., S19MHT stated the MHTs conduct the activity groups on Wednesdays. S19MHT stated yesterday (Wednesday, 06/14/17) they tried to do an activity with the patients called Pictionary. S19MHT stated that Patient #4 was the only patient that was able to do the activity, so they stopped and changed the activity to painting.

In an interview on 06/15/17 at 7:55 a.m., S15CM indicated she does activities that all patients can take part in, even demented patients, such as music therapy and exercising. She further indicated she does groups on Tuesday, Thursday, and Friday. She confirmed no certified recreational therapeutic specialist is providing activity therapy on Monday, Wednesday, and weekends. S15CM stated she leaves a variety of activities that the MHTs can pick from for the days she is not present. S15CM confirmed therapeutic activities was on the schedule for Mondays, but due to treatment plan meetings the only time she did activities on a Monday is when S6MedDir was on vacation. S15CM confirmed a patient admitted on a Friday afternoon would not receive therapeutic activities until Tuesday morning. S15CM confirmed therapeutic activities are not included in the patient's treatment plan. She stated she attended the treatment plan meetings but did not develop an individualized plan of activity therapy for the patient.

In an interview on 06/15/17 at 9:05 a.m., S6MedDir stated the patient's activity therapy participation and response was discussed during treatment team meetings. S6MedDir confirmed he would expect to see individualized therapeutic activities included in the patient's treatment plan. S6MedDir confirmed patients should have therapeutic activities provided at their individual level of functioning. S6MedDir confirmed activity therapy should be provided five times a week. S6MedDir confirmed MHTs providing activities should be supervised by a higher level staff.




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