HospitalInspections.org

Based on review of the hospital's institutional budget and plan, and interview, the hospital failed to ensure a plan for capital expenditures for at least a 3 year period, including the year in which the annual operating budget is prepared.

The findings are:

On 08/11/15 at 10:55 a.m., review of the hospital's institutional budget plan revealed there was no 3 year capital expenditures plan. On 08/11/15 at 11:20 a.m., the Chief Financial Officer revealed, "that is just something we have never done. I've done this for 20 years and have never done a 3 year plan. It's just not standard practice to do a 3 year plan".

Based on review of the hospital's Quality Assessment and Performance Improvement (QAPI) data and interview, the hospital failed to ensure that avoidable healthcare-acquired infections were integrated into the QAPI program.

The findings are:

On 08/12/15 at 1:00 p.m., review of the hospital's QAPI data revealed there was no evidence that healthcare-acquired infections were monitored, trended, or analyzed in the hospital's QAPI plan.
On 08/12/15 at 2:20 p.m., the Infection Control Officer (ICO) revealed, "The only infection information relayed to the Quality Leadership Committee (QLC) is the "Infection Control Surveillance" forms that monitor the environmental aspect of the hospital.

Based on interview, record review, and review of the hospital's policy and procedures, the hospital failed to ensure the patient's vital signs were obtained per physician orders for 2 of 26 open patient charts reviewed for nursing care and services (Patient 10 and 15) and failed to obtain finger stick blood sugars per physician orders for 1 of 26 open patient charts reviewed for nursing care and services. (Patient 13).

The findings are:

On 08/11/15 at 11:50 a.m., review of Patient 10's chart revealed the patient was admitted on 07/21/15 for unspecified psychosis. Review of physician orders dated 07/21/15, revealed, "vital signs 2 x (times)/day (2 times per day)". Review of the patient's flow sheet with the recorded vital signs showed no vital signs were recorded on 7/25/15 at 6:00 p.m. and 07/26/15 at 6:00 p.m.. On 08/12/15 at 11:42 a.m., Unit Director 1 verified the patient's vital signs were not recorded on those dates.
On 08/11/15 at 3:11 p.m., review of Patient 15's chart revealed the patient was admitted on 08/09/15. Review of physician orders dated 08/09/15 at 6:00 p.m. revealed an order for "VS (vital signs) QID (four times a day) x (times) 3 days, then BID (two times a day)". Review of vital signs flow sheet in the patient's chart revealed there was no documentation of the vital signs that should have been obtained at 12:00 a.m. on 08/09/15. On 08/11/15 at 3:30 p.m., Unit Director 1 verified the finding and stated, "the vitals are to be documented on the graphic sheet".
Hospital policy, titled, "Physician's Orders", reads, "....7. All physician orders must be signed off by a licensed nurse. The nurse shall enter the date and time the order is carried out and must write his/her signature and title to indicate her acknowledgement of the order and that he/she has taken responsibility for carrying the orders out....".
Hospital policy, titled, "Vital Sign Monitoring", reads, "Procedure: 1. Vital signs will be taken routinely on all patients upon admission and twice daily unless otherwise ordered by the physician....".
On 08/11/15 at 1:32 p.m., review of Patient 13's chart revealed the patient was admitted on 08/08/15 for suicidal ideation. Review of physician orders dated 08/08/15 at 11:00 a.m. revealed, "chem (chemistry) stick (finger stick) q (every) am (morning)". Review of the Blood Glucose Monitoring flow sheet in the patient's chart revealed there was only one blood sugar charted on 08/11/15 at 6:00 a.m. that resulted at 118. On 08/12/15 at 11:48 a.m., Unit Director 1 verified there was no other documentation of the patient's Blood Glucose results.
Hospital policy, titled, "Finger stick glucose monitoring", reads, "....Procedure: 1. Semi-quantitative glucose level testing is to be administered prior to meals and evening snack unless ordered differently by M.D. (medical doctor)....4. Document the results on the Blood Glucose Monitoring Flow Sheet....".

Based on record review, interview, and review of the hospital's policy and procedures, the hospital failed to ensure a medical history and physical was completed for 1 of 26 open patient charts reviewed for the completion of patient history and physicals. (Patient 10).

The findings are:

On 08/11/15 at 11:50 a.m., review of Patient 10's chart revealed the patient was admitted on 07/21/15 at 9:25 a.m.. Review of the medical history and physical in the patient's chart revealed, "Interval Medical History and Physical" that was dated 07/21/15. Documentation of the form stated, "This form may be used when a patient is re-admitted within 30 days for the same or related problems. The interval assessment should reflect any changes since discharge, and should be accompanied by a copy of the original assessment". Review of the accompanied original history and physical assessment revealed a medical history and physical dated 05/25/15 which is greater than 30 days of the current admission dated 07/21/15. On 08/12/15 at 2:45 p.m., Unit Director 1 reported, "the doctor has 30 days from the discharge date of the last admission and can complete an interval medical history and physical". Hospital policy, titled,"Assessments/Reassessments/Consultations", reads, "....Procedure: 1. History and Physical Examination: A completed history and general physical examination is to be completed on each patient within 24 hours of admission by the medical consultant....".

Based on observation, interview, and review of facility policies and procedures, the hospital failed to maintain a sanitary environment in the dietary area, and failed to ensure appropriate water temperature in the dietary dishwasher.

The findings are:

On 08/10/15 at 1:20 p.m., random observation of the dietary walk-in refrigerator and walk-in freezer revealed food items located on the floor of each unit. On 08/10/15 at 1:20 p.m., interview with dietary staff 1 revealed a delivery was made on Friday.
On 08/10/15 at 1:30 p.m., random observation of the dietary refrigerator located by the entrance into the kitchen area revealed a container with sour cream and sliced cucumbers without a date and time when opened, a bag of coleslaw expired 07/06/15 and a plastic jar of Pace salsa without a date and time when opened. On 08/10/15 at 1:30 p.m., findings verified by dietary staff 1.
On 08/10/15 at 1:48 p.m., random observation of the dietary emergency food storage area revealed no emergency water supply for the facility. On 08/10/15 at 1:48 p.m., findings verified by manager 1.
On 08/10/15 at 1:57 p.m., observation of the dietary dishwasher revealed the wash temperature gauge reached a temperature of 118-120 degrees during two separate washes. On 08/10/15 at 1:57 p.m., findings verified by dietary staff 1.

Based on observations and interview, the hospital failed to ensure the
environment was safe for patients related to loose/missing ceiling tiles, missing vent grills, loose exhaust fan, over flow of trash, and linen housed with electrical equipment.


The findings include:


On 08/10/2015 at 1:15 p.m., observations of the hospital's laundry room in the common hallway revealed two ceiling tiles, one missing and one loose. Continued observations revealed in room 75 the exhaust fan in the patient bathroom was loose from the ceiling, in the biohazard room which also housed the computer board and thermostat equipment was an industrial size trash can overflowing with trash, and in room 110 there was no vent grill on the ceiling vent in the patient bathroom. The Facility Manager verified the findings on 08/10/2015 at 2:20 p.m.

Based on interview and review of hospital infection control data, the hospital failed to have a policy and/or procedure related to construction, renovation, maintenance, demolition, and repair including an infection control risk assessment (ICRA) for projects and barrier measures, and failed to develop a hospital policy related to resistant organisms (MDRO).

The findings are:

On 08/11/15 at 10:40 a.m., review of the hospital's infection control data documentation revealed there was no documentation of an infection control risk assessment related to past renovations of hospital areas. On 08/11/15 from 10:45 a.m. - 10:50 a.m., Manager 2 reported the the hospital had not been using an infection control risk assessment tool for maintenance or repair and the last construction in the hospital occurred about a year ago. Unit Manager 2 reported that a pre-assessment tool had been developed but not approved for use yet.
On 08/11/15 at 11:15 a.m., review of the hospital's infection control program data revealed the hospital had no policy for multi-drug resistant organisms (MDRO). On 08/11/15 at 11:15 a.m., the Infection Control Officer revealed, "We do not have a policy on MDRO's".

On 08/10/2015 at 2:15 p.m., observations during a tour of the physical environment showed a 16 French Foley catheter out of the package and a 60 ml (milliliter) syringe lying on the back of the patient bathroom sink in room 101. Further investigation with the RN 3 revealed the patient in room 101 was using the catheter for self catheterization irrigations. RN 3 stated the patient should be using a new sterile catheter each time and placing the old ones in a biohazard bag each time. RN 3 verified the finding on 08/10/2015 at 2:30 p.m.



31395

Based on observations, interview, and review of the hospital's policies and procedures, the hospital failed to ensure that 1 of 3 Registered Nurses (RN 1) observed during medication administration performed hand hygiene between patients according to accepted principles of infection control and the hospital's policies and procedures (RN 1) and failed to ensure patient equipment was maintained in it packaging until use. (Foley Catheter)

The findings are:

On 08/11/15 at 2:05 p.m., observations of Registered Nurse(RN) 1 during the medication administration task revealed RN 1 administered the medication to 4 different patients and performed hand hygiene between patients, but only washed his/her hands for 7 - 10 seconds each time. RN 1 failed to perform adequate hand washing. On 08/11/15 at 2:25 p.m., RN 1 revealed, "I did not wash my hands long enough. I should have washed for 15 seconds. Normally I use the hand sanitizer".
Hospital Policy and Procedure, titled, "Hand Hygiene", reads, "....3. Hand-hygiene technique....B. When washing hand with soap and water, wet hands first with water, apply and apply amount of product recommended by the manufacturer to hands, and rubhands together vigorously for a least 20 seconds, covering all surfacces of the hands and fingers....".

Based on record review, observation and interview the facility failed to:
l. Develop and document comprehensive multidisciplinary treatment plans formulated from individual needs of the patients for eight (8) of eight (8) sample patients (B1, B2, B3, B4, A1, A2, A3 and A4). In addition it failed to follow hospital policy regarding documentation of short term goals and interventions. Patients' treatment plans were completed by the admitting RN, rather than by their treatment teams. Failure to develop and document treatment plans based on patient needs, limits staff ability to address the patients' need for inpatient care and can extend the length of hospitalization. (B118)

ll. Develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, time limited behavioral terms for five (5) of eight (8) active patients (B1, B2, B3, A3 and A4). Lack of patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment. (B121)

lll. Identify in the MTP specific treatment interventions/modalities to address the identified patient problems for eight (8) of eight (8) active sample patients (B1, B2, B3, B4, A1, A2, A3 and A4). Interventions listed on treatment plans were preprinted. The treatment interventions listed were stated in vague terms and were non-individualized generic discipline functions rather than individualized patient specific interventions. In addition, recreation therapy on all plans did not list interventions and only noted "Rec [Recreation] therapy". This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients. (B122)

lV. Provide active therapeutic programming for all the patients on Units A and B (32 patients). Groups were often not started on time, were changed from the scheduled group times, were cancelled or patients were allowed to leave group after a brief period. Failure to offer groups that focus on the need for inpatient psychiatric care limits the patients' ability to recover and can extend the period of hospitalization. (B125-l)

V. Ensure that the nursing staff monitored patients on suicidal precautions. Failure to monitor patients as ordered places patients at risk of harm and can lead to negative outcomes. (B125-ll)

Based on record review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient centered assets in descriptive fashion for four (4) of eight (8) active sample patients (B1, B4, A2 and A4). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings Include:

Medical Record Review:

1. Patient B1's psychiatric evaluation dated 6/17/15 listed for patient assets "[His/her] daughter is very supportive."

2. Patient B4's psychiatric evaluation dated 6/16/15 listed for patient assets " [He/she] appears to have a supportive family."

3. Patient A2's psychiatric evaluation dated 7/18/15 listed for patient assets "The patient is disabled, physically healthy."

4. Patient A4's psychiatric evaluation dated 7/21/15 listed for patient assets "The [sic] reports [he/she] likes hacking computers and [he/she] like electronics. Also [he/she] reports supportive sister with whom [he/she] is living with [sic].

Interviews:

1 In an interview with the COO (Chief Operating Officer) on 7/28/15 at 4:00 PM, the lack of documented patient focused assets was discussed and she concurred with the findings.

2. In an interview with the Medical Director on 7/28/15 at 1:00 PM, he agreed that patient assets were not documented strengths the patient could use to help in formulating treatment plan goals.

Based on medical record review, observation, policy review and interview, the facility failed to develop and document comprehensive multidisciplinary treatment plans formulated from individual needs of the patients for eight (8) of eight (8) sample patients (B1, B2, B3, B4, A1, A2, A3 and A4). In addition it failed to follow hospital policy regarding documentation of short term goals and interventions.. Patients' Master Treatment Plans were completed by the admitting RN, rather than by their treatment teams. Failure to develop and document treatment plans based on patient needs, limits staff ability to address the patients' need for inpatient care and can extend the length of hospitalization.

Findings include:

1. Long-term and short-term treatment goals were not measurable or patient-centered for five (5) of eight (8) sample patients (B1, B2, B3, A3 and A4). (Refer to B121)

2. The preprinted treatment interventions developed for patients on the Master Treatment Plans were generic discipline functions and not individualized for eight (8) of eight (8) sample patients (B1, B2, B3, B4, A1, A2, A3 and A4). (Refer to B122)

3. Staff responsibilities for accomplishing treatment interventions were not consistently listed for physicians and social work. Listing for nursing and activity therapy were documented by initials and not discipline for three (3) of eight (8) sample patients (B2, B3 and B4). (Refer to B123)

A. Observation

1. Surveyors attended the treatment team/treatment planning meeting on 7/28/15 from 8:30 AM until 9:15 AM. During the meeting, staff focus/discussion was a patient report/discharge planning focus. There was no mention of patient short term goals or treatment interventions that were reflected on the treatment plans. Patients were not brought into this meeting.

B. Policy Review

1. Hospital Policy and Procedures in the Behavioral Health System Hospital Clinical Manual lists Policy #110-001-R8 (Revised 5/15) and requires "Goals are stated as observable, measurable and relevant, describing action, or behavior to be achieved. Interventions are stated to include plan of approach, modalities, frequency, and time, with who is responsible for implementation of the interventions and target date."

C. Interview

1. In an interview on 7/28/15 at 11:15 AM with the Clinical Services Director, she concurred the Treatment Team Meeting on 7/28/15 at 8:30 AM did not contain a discussion of patients' treatment plans or treatment plan updates. She noted each discipline prepared their part of the plan especially with regard to treatment updates. She stated the Master Treatment Plan is prepared by nurses and disciplines complete their portions of the plan separately. She further concurred there is not a formal system for evaluating either the quality or completeness of the treatment plans. She stated that she prepares a summary of the team meeting content but it is not placed in the medical record.

2. In an interview on 7/28/15 at 1:00 PM the Clinical Director concurred that the treatment team meeting on 7/28/15 at 8:30 AM did not contain discussion of the patients' treatment plan or updates. He concurred that the document was largely prepared by the nursing staff and did not reflect the functions of a treatment team. He concurred that each discipline prepared their part of the plan independently and nursing completed the physician portion of the plan

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, time limited behavioral terms for five (5) of eight (8) active patients (B1, B2, B3, A3 and A4). Lack of patient specific goals hampers the treatment team ' s ability to assess changes in patients' condition as a result of treatment.

Findings Include:

A. Record Review

1. Patient B1 was admitted on 6/16/15 with a diagnosis of "Paranoid Schizophrenia, chronic with acute exacerbation." The Master Treatment Plan (MTP) dated 6/16/15 listed the following problems: "Psychosis, HTN [Hypertension], and anxiety." For the problem of "anxiety" the short term goals listed were "Patient can identify causes of anxiety as able; Patient can identify positive coping skills to decrease daily increased level of anxiety as able; Patient will verbalize understanding of meds [medications] side effects and effectiveness and importance of compliance as able."

In an interview on 7/27/15 at 3:30 PM the physician surveyor asked the patient orientation questions, reasons for being in the hospital, etc. Patient B1 answered those questions with the response, "Someone stole my bod [body]".

2. Patient B2 was admitted on 7/6/15 with a diagnoses of "Psychosis, NOS; Likely Bipolar disorder, manic." The MTP dated 7/7/15 listed the following problems: "Bizarre thought processes, HTN, hyperlipidemia." For the problem of "bizarre thought process", the short term goals listed were, "Patient will report diminished or absence of hallucination; Patient will be oriented to person, place, and time and situation for 3 consecutive days." The goals are incongruent with the psychiatric evaluation dated 7/8/15 which indicated "[She/He] does not appear to be hallucinating" and "[she/he] is fairly oriented".

3. Patient B3 was admitted on 7/9/15 with a diagnoses of "Substance use disorder (opiates and benzodiazepines), likely withdrawal from both currently; Major depression by history." The MTP dated 7/9/15 listed the following problems: "Depression; Chronic Pain, COPD [Chronic Obstructive Pulmonary Disease], Lupus, GERD [Gastroesophageal Reflux Disease], Anxiety". There was no problem definition for the patient's primary problem of substance use and therefore no short term goals listed regarding this problem.

4. Patient A3 was admitted 6/30/15 with a diagnoses of "depressive Disorder NOS; Psychotic disorder NOS; Rule out schizoaffective disorder, depressed type. " The MTP dated 7/1/15 had listed for the problem," thought disorder/Psychosis" the following non-measurable short term goals: "Patient will report diminished or absence of hallucinations" and "Patient will be compliant with medications requiring minimal prompting to take medication"

5. Patient A4 was admitted on 7/18/15 with a diagnosis of "bipolar disorder, NOS, most recent episode". The MTP dated 7/18/15 for the problem listed "Excessive anxiety". The following non-measurable short term goals: "Patient can identify causes of anxiety"; "Patient can identify positive coping skills to decrease daily increase level of anxiety," and Patient will verbalize understanding of meds, side effects and effectiveness and importance of compliance".

B. Interview

1.In an interview on 7/28/15 at 10:30 AM, the COO [Chief Operating Officer] agreed that patient short term goals were not consistently observable, measurable, and time limited. Further they did not always reflect problem statements nor were the goals consistent with the patients' diagnosis or problem.

2. In an interview on 7/28/15 at 11:15 AM, the Clinical Services Director concurred that patient short term goals were not consistently observable, measurable, and time limited. Further the short term goals did not always reflect problem statements consistent with the patients' diagnosis or problem.

3. In an interview on 7/28/15 at 1:00 PM the Clinical Director concurred that patient short term goals were not consistently observable, measurable, and time limited. Further the short term goals did not always reflect problem statements consistent with the patients' diagnosis or problem.

Based on record review and interview, the facility failed to identify in the MTP specific treatment interventions/modalities to address the identified patient problems for eight (8) of eight (8) active sample patients (B1, B2, B3, B4, A1, A2, A3 and A4). Interventions listed on treatment plans were preprinted. The treatment interventions listed were stated in vague terms and were non-individualized generic discipline functions rather than individualized patient specific interventions. In addition, recreation therapy on all plans did not list interventions and only noted "Rec [Recreation] therapy". This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

Findings Include:

A. Medical Record Review

1. Patient B1 was admitted on 6/16/15 with a diagnosis of "Paranoid Schizophrenia chronic with acute exacerbation". The Master Treatment Plan (MTP) dated 6/16/15 listed the following problems: "Psychosis, HTN [Hypertension], and anxiety." Treatment interventions listed for the problem "Psychosis" were "Q [Every] 15 minute checks to assess behaviors and patient safety" and "Monitor and assess mental and physical status daily; Make medication change as needed.; Rec therapy".

2. Patient B2 was admitted on 7/6/15 with a diagnosis of "Psychosis, NOS; Likely Bipolar disorder, manic." The MTP dated 7/7/15 listed the following problems: "Bizarre thought processes, HTN, hyperlipidemia." Treatment interventions listed for "Bizarre thought processes were" Q15 minute checks to assess behaviors and patient's "safety" and "Rec therapy".

3. Patient B3 was admitted on 7/9/15 with a diagnosis of "Substance use disorder (opiates and benzodiazepines), likely withdrawal from both currently; Major depression by history." The MTP dated 7/9/15 listed the following problems: "Depression; Chronic Pain, COPD, Lupus, GERD, Anxiety" The problems listed for this patient did not include a problem of substance use despite the patient's diagnosis. Treatment interventions listed for the problem of "Chronic Pain" were "Assess effectiveness of medication; Assess hours of uninterrupted sleep at night; educate regarding effective pain management."

4. Patient B4 was admitted on 7/10/15 with a diagnosis of "Mood D/O [Disorder] NOS; Psychosis NOS; R/O [rule Out] Dementia." The problems listed on the MTP dated 7/10/15 included "Alteration in Mood, Depressed; Alteration Health, GERD [Gastroesophageal Reflux Disease]; Falls; Pain." Treatment interventions listed for the problem of "Alteration in Mood, Depressed" were "Q 15 minute observation for safety; Medication as ordered for Depression: Educate re: benefits and side effects; Rec therapy."'

5. Patient A1 admitted on 7/6/15 with diagnoses of "Benzodiazepine Withdrawal; Benzodiazepine physical dependence; Major depression, by history". The problems listed on the MTP dated 7/6/15 were "Substance Abuse; Depression; HTN; GERD; Chronic Pain, Migraines, Arthritis; Falls Diabetes. Treatment interventions listed for the problem of "Benzos" [benzodiazopines] were "evaluate need for medication changes; Monitor vital Signs per Detox Protocol; Rec Therapy."

6. Patient A2 was admitted on 7/18/15 with diagnoses of "Depression and Dementia." The problems listed on the MTP dated 7/18/15 were "Thought Disorder/Psychosis, Alteration in Mood: Depressed." Treatment interventions listed for the problem of "Thought Disorder/Psychosis" were "Monitor and assess mental and physical status daily. Make medication changes as needed; Q15 minute checks to assess behaviors and patient safety; Provide reality oriented feedback, redirection and verbal cues."

7. Patient A3 was admitted 6/30/15 with a diagnoses of "depressive Disorder NOS; Psychotic disorder NOS; Rule out schizoaffective disorder, depressed type." The MTP dated 7/1/5 listed the problems, "thought disorder/Psychosis and Benzodiazepine Withdrawal". Treatment interventions listed were "Assess patient daily to assess treatment progress, withdrawal signs and symptoms", "Q 15 minute checks to assess behaviors and patient safety: Administer medications as ordered and educate patient re: side effects and benefits of medication."

8. Patient A4 was admitted on 7/18/15 with a diagnosis of "bipolar disorder, NOS, most recent episode". The MTP dated 7/18/15 identified the problem, "Alteration in Mood: Depressed". Treatment interventions listed for this problem were "Q 15 minute observations for safety, Assess for suicidal ideations and changes in mood; Environmental checks/ to provide safe environment".

B. Interview

1. In an interview on 7/28/15 at 10:30 AM, the COO [Chief Operating Officer] agreed that staff interventions listed on the MTP were not patient specific and often reflected routine generic job functions. Further they did not always reflect problem statements consistent with the patients' diagnosis or problem.

2. In an interview on 7/28/15 at 11:15 AM with the Clinical Services Director, she concurred that staff interventions were not patient specific and were generic in nature. Further the short term goals did not always reflect problem statements consistent with the patient's diagnosis or problem.

3. In an interview on 7/28/15 at 1:00 PM, the Clinical Director concurred that MD goals were completed by the nurses and did not reflect patient specific physician interventions.

Based on record review and interview, the hospital failed to identify by name and discipline the team member responsible for the modalities/interventions selected on MTPs for three (3) of eight (8) active patients (B2, B3 and B4). The treatment plans listed only staff initials and did not identify the specific names and disciplines of those staff members responsible for treatment modalities/interventions. In addition treatment plans reviewed did not identify physician or social work staff responsible for the preprinted interventions listed on the MTP's. This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment.

Findings Include:

A. Record Review

1. Patient B2 was admitted on 7/6/15 with a diagnosis of "Psychosis, NOS; Likely Bipolar disorder, manic." The MTP dated 7/7/15 listed only nursing and recreation therapy staff initials for those persons responsible for providing care to the patient. There was no listing of staff responsible for either physicians or social workers noted on the plan.

2. Patient B3 was admitted on 7/9/15 with a diagnosis of "Substance use disorder (opiates and benzodiazepines), likely withdrawal from both currently; Major depression by history." The MTP dated 7/9/15 listed only nursing and recreation therapy staff initials for those persons responsible for providing care to the patient. There was no listing of staff responsibility for either physician or social work.

3. Patient B4 was admitted on 7/10/15 with a diagnosis of "Mood D/O [Disorder] NOS; Psychosis NOS; R/O [rule Out] Dementia." The MTP dated 7/10/15 listed only nursing and recreation therapy staff initials for those persons responsible for providing care to the patient. There was no indication of social work or physician responsibility listed on the MTP.

B. Interview

1. In an interview on 7/28/15 at 10:30 AM, the COO concurred that MTPs did not consistently list staff responsible for treatment interventions and did not specifically identify staff name and discipline.

2. In an interview on 7/28/15 at 11:15 AM with the Clinical Services Director, she agreed that social work staff were not regularly listed on treatment plans.

3. In an interview on 7/28/15 at 1:00 PM, the Clinical Director concurred that MD's were not listed consistently on the treatment plans. He further concurred that the MTP was primarily completed by nurses and physicians relied on nurses to complete the physician part of the plan.

Based on record review, observation and interview, the facility failed to:
l. Provide active therapeutic programming for all the patients on Units A and B (32 patients). Groups were often not started on time, were changed from the scheduled group times, were cancelled or patients were allowed to leave group after a brief period. Failure to offer groups that focus on the need for inpatient psychiatric care limits the patients' ability to recover and can extend the period of hospitalization.

ll. Ensure that the nursing staff monitor patients on suicidal precautions. Failure to monitor patients as ordered places patients at risk of harm and can lead to negative outcomes.

Findings include:

l. Therapeutic Programming

A. Observations/Interviews

1. The Recreation Group scheduled on Unit B from 2:15-3:15 PM on 7/27/15 did not occur. During interview on 7/28/15 at 11:55 AM, RT1 stated that she had held the group from 10:45 AM-11:30 AM (when Gym/Physical Education group was scheduled) but it had not been corrected on the schedule. Nothing was offered during the 2:15 PM-3:15 PM time.

2. The Social Work Group, "What is Anger?" for Unit A was held outside from 2:30 PM-3:15 PM on 7/27/15. At 2:45 PM, Patient A4 and three other patients returned to the unit, leaving eight patients in the group. Patient A4 stated, "It's too hot out there." The seven (7) patients not attending group were either in their rooms or sitting in the dayroom. When MHA2 was asked what alternative intervention was offered to the patients not attending group, stated that nothing was offered and that Patient A4 "just walks the halls."

3. The AT (Activity Therapy) or Arts and Crafts (MHA) Group scheduled on Unit A from 3:15 PM-4:15 PM on 7/27/15 did not occur. When MHA2 was asked about the group, she stated "I don't know who's doing the AT group but if they don't come, I'll do something." At 3:30 PM, the surveyor observed six (6) patients watching television. At 3:50 PM, there was still not a group in progress and patients continued to watch the television.

4. The Social Work Group scheduled on 7/27/15 from 3:15 PM-4:00 PM on Unit B started at 3:35 PM. The Social Worker took five (5) female patients from the dayroom to form the group, leaving 13 patients not involved in active treatment.

5. The Nurse Group Diagnostic/Medications Group scheduled on 7/27/15 from 4:00 PM-4:30 PM on Unit B did not occur. Instead the MHAs on Unit B started a movie for patients sitting in the dayroom.

6. The Life Skills Group scheduled on 7/27/15 from 4:15 PM-4:45 PM on Unit A did not occur. At 4:30 PM there were five (5) patients observed watching television.

7. The Communication Skills Group scheduled from 10:00 AM-10:45 AM on 7/28/15 on Unit B did not occur. During this time, observations revealed seven (7) patients in bed and four (4) patients with their eyes closed, lying on couches.

ll. Patient Monitoring

A. Specific Patient Findings

1. Patient C1 was admitted on 7/27/15. The Acute Intake information provided by the referral source on 7/27/15 at 6:33 PM, listed the Chief Complaint as "Depression, Self Mutalization [sic] and SI [Suicidal Ideation]." The patient was noted to have "superficial cut to wrist, hx [history] suicide attempt, hx of abuse." The Nursing Assessment, dated 7/27/15 at 10:00 PM, listed "suicidal thoughts" as "fleeting." The "yes" box was checked to indicate "Previous self injury/behaviors." Review of the Admission Nurse's Note dated 7/27/15 at 10:00 PM described Patient C1 as "Pt [patient] has cut [his/her] right FA [forearm]. All superficial [except] one farthest up arm is slightly open. Area covered [with] gauze tape at this time. Pt admits to fleeting thoughts of suicide. Has attempted one other time before. Pt called crisis line after cutting [himself/herself]...Will continue to monitor for safety." The Physicians Admission Order Sheet (verbal orders) dated 7/27/15 at 11:55 PM placed Patient C1 on "Suicide Precautions". The choices for "Level of Observation" related to suicide precautions were listed as "Continuous (1:1), Continuous (visual) and Every 15 minute checks." None of the boxes were checked to indicate the Level of Observation for the Suicide Precautions. Review of the Hospital Unit Observation Log revealed that Patient C1 was being observed every 15 minutes. There was however no record of monitoring from 2:45 AM-3:15 AM on 7/28/15. There was also no record of patient monitoring from 7:00 AM-9:30 AM on 7/28/15. In addition, as of 9:30 AM on 7/28/15 there was no documentation that the patient had been assessed by a psychiatrist/nurse practitioner.

2. Patient C2 was admitted on 7/27/15. The Acute Intake information provided by the referral source on 7/27/15 at 3:00 PM, listed the Chief Complaint as "SI [Suicidal Ideation] [I] don't want to live anymore." The Physicians Admission Order Sheet (verbal orders) dated 7/27/15 at 11:50 PM placed Patient C2 on "Suicide Precautions". The "Level of Observation" was checked as "Every 15 minute checks." Review of the Hospital Unit Observation Log revealed that Patient C2 was being observed every 15 minutes. There was however no record of monitoring from 2:45 AM-3:15 AM on 7/28/15. There was also no record of patient monitoring from 7:00 AM-9:30 AM on 7/28/15. In addition, as of 9:30 AM on 7/28/15 there was no documentation that the patient had been assessed by a psychiatrist/nurse practitioner.

B. Observations

1. At 8:30 AM on 7/28/15, the surveyors entered Unit A to attend a treatment team meeting in a closed room at the end of the unit. The surveyors were told by RN3 that the patients and staff had left the unit to go to breakfast. At 9:15 AM, as surveyors were leaving the treatment team room and passing the patient rooms, Patient C1 was observed in bed with the lights off. There was no staff on the unit.

2. At 9:20 AM, as surveyors were looking at Patient C1's record on Unit A, Patient C2 came out of his/her room and went into the dayroom.

C. Interviews

1. The Adult Unit Director was with the surveyors at 9:15 AM when Patient C1 and C2 were observed unattended on Unit A. She acknowledged that there was no staff on the unit and that both patients were on Suicide Precautions.

2. During interview on 7/28/15 at 9:30 AM, Mental Health Associate 3 (MHA3) stated that the MHA staff and patients had left the unit for breakfast at approximately 8:00 AM and had then gone outside to smoke. She stated that they had been off the unit "longer than usual". MHA3 stated that she did not realize that the RN on the ward would be in a Treatment Team meeting and unavailable to monitor the two patients left in bed.

Based on record review, interview and observation the facility failed to provide adequate numbers of registered nurses (RNs) to ensure that a RN was consistently available on Unit A to provide care to patients and to direct and supervise the non-professional nursing personnel. This failure places non-licensed staff in the position of providing care that should be supervised by a RN and creates potential safety concerns for the patients. (Refer to B150)

Based on medical record review, interview, and observation, the Medical Director failed to ensure:

I. The provision of psychiatric evaluations that included an assessment of patient centered assets in descriptive fashion for four (4) of eight (8) active sample patients (B1, B4, A2 and A4). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (See B117)

II. The development and documentation of comprehensive multidisciplinary treatment plans formulated from individual needs of the patients for eight (8) of eight (8) sample patients (B1, B2, B3, B4, A1, A2, A3 and A4). In addition he/she failed to ensure compliance with hospital policy regarding treatment planning. Patients' treatment plans were completed by the admitting RN, rather than by their treatment teams. Failure to develop and document treatment plans based on patient needs, limits staff ability to address the patients' need for inpatient care and can extend the length of hospitalization. (B118)

III. The development of Master Treatment Plans (MTP) that identified patient-centered short-term goals stated in observable, measurable, time limited behavioral terms for five (5) of eight (8) active patients (B1, B2, B3, A3 and A4). Lack of patient specific goals hampers the treatment team's ability to assess changes in patients' condition as a result of treatment. (B121)

IV. The identification in the MTP specific treatment interventions/modalities to address the identified patient problems for eight (8) of eight (8) active sample patients (B1, B2, B3, B4, A1, A2, A3 and A4). Interventions listed on treatment plans were preprinted. The treatment interventions listed were stated in vague terms and were non-individualized generic discipline functions rather than individualized patient specific interventions. In addition, recreation therapy on all plans did not list interventions and only noted "Rec [Recreation] therapy". This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients. (B122)

V. The identification by name and discipline the team member responsible for the modalities/interventions selected for three (3) of eight (8) active patients on MTPs. (B2, B3 and B4) The treatment plans listed only staff initials and did not identify the specific names and disciplines of those staff members responsible for treatment modalities/interventions. In addition treatment plans reviewed did not identify physician or social work staff responsible for the preprinted interventions listed on the MTP's. This has the potential to create a lack of ability to determine which staff member is responsible for ensuring compliance with the various aspects of treatment. (See B123)

VI. The provision of active therapeutic programming for all the patients on Units A and B (32 patients). Groups were often not started on time, were changed from the scheduled group times, were cancelled or patients were allowed to leave group after a brief period. Failure to offer groups that focus on the need for inpatient psychiatric care limits the patients' ability to recover and can extend the period of hospitalization. (B125-l)

VII. That the nursing staff monitored patients on suicidal precautions. Failure to monitor patients as ordered places patients at risk of harm and can lead to negative outcomes. (B125-ll)

Based on record review, observation and interview, the Director of Nursing failed to:

l. Identify in the MTP specific nursing interventions to address the identified patient problems for seven (7) of eight (8) active sample patients (B1, B2, B4, A1, A2, A3 and A4). Interventions listed on treatment plans were preprinted. The nursing interventions listed were stated in vague terms and were non-individualized, generic discipline functions rather than individualized patient specific nursing interventions. This deficiency results in failure to guide treatment staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for patients.

ll. Identify by name and discipline the nursing team member responsible for the interventions selected for three (3) of eight (8) active patients. (B2, B3 and B4) The treatment plans listed only nursing staff initials and did not identify the specific names and disciplines of those nursing staff responsible for treatment interventions. This has the potential to create a lack of ability to determine which nursing staff member is responsible for ensuring compliance with the various aspects of treatment.

lll. Ensure that the nursing staff monitors patients on suicidal precautions. Failure to monitor patients as ordered places patients at risk of harm and can lead to negative outcomes. (Refer to B125 ll)

lV. Provide adequate numbers of registered nurses (RNs) to ensure that a RN was consistently available on Unit A to provide care to patients and to direct and supervise the non-professional nursing personnel. This failure places non-licensed staff in the position of providing care that should be supervised by a RN and creates potential safety concerns for the patients. (Refer to B150)

Findings include:

l. Interventions

A. Record Review

1. Patient B1 was admitted on 6/16/15 with a diagnosis of "Paranoid Schizophrenia chronic with acute exacerbation". The Master Treatment Plan (MTP) dated 6/16/15 listed the problem "Psychosis ". The nursing intervention for this problem was, "Q [Every] 15 minute checks to assess behaviors and patient safety".

2. Patient B2 was admitted on 7/6/15 with a diagnosis of "Psychosis, NOS; Likely Bipolar disorder, manic." The MTP dated 7/7/15 listed the following problems: "Bizarre thought processes, HTN, hyperlipidemia." The nursing interventions listed for "Bizarre thought processes" was, "Q15 minute checks to assess behaviors and patient's safety".

3. Patient B4 was admitted on 7/10/15 with a diagnosis of "Mood D/O [Disorder] NOS; Psychosis NOS; R/O [rule Out] Dementia." The MTP dated 7/10/15 listed the problem "Alteration in Mood, Depressed". The nursing intervention for this problem was "Q 15 minute observation for safety" and "Medication as ordered for Depression".

4. Patient A1 admitted on 7/6/15 with diagnoses of "Benzodiazepine Withdrawal; Benzodiazepine physical dependence; Major depression, by history". The nursing intervention listed for the problem, "Benzos" [benzodiazopines] was "Monitor vital Signs per Detox Protocol".

5. Patient A2 was admitted on 7/18/15 with diagnoses of "Depression and Dementia." The problems listed on the MTP dated 7/18/15 included "Thought Disorder/Psychosis". The nursing interventions for this problem were, "Q15 minute checks to assess behaviors and patient safety" and "Provide reality oriented feedback, redirection and verbal cues."

6. Patient A3 was admitted 6/30/15 with a diagnoses of "depressive Disorder NOS; Psychotic disorder NOS; Rule out schizoaffective disorder, depressed type." The MTP dated 7/1/5 listed the problem "thought disorder/Psychosis1 and Benzodiazepine Withdrawal". Nursing interventions listed for this problem were, "Q 15 minute checks to assess behaviors and patient safety: Administer medications as ordered and educate patient re: side effects and benefits of medication."

7. Patient A4 was admitted on 7/18/15 with a diagnosis of "bipolar disorder, NOS, most recent episode". The MTP dated 7/18/15 listed the problem, "Alteration in Mood: Depressed'. Nursing interventions for this problem were, "Q 15 minute observations for safety, Assess for suicidal ideations and changes in mood; Environmental checks/ to provide safe environment".

B. Interview

In interview on 7/28/15 at 10:30 AM, the COO [also functioning as the Director of Nursing] agreed that nursing interventions listed on the MTP were not patient specific and often reflected routine generic job functions.

ll. Responsible Staff

A. Record Review

1. Patient B2 was admitted on 7/6/15 with a diagnosis of "Psychosis, NOS; Likely Bipolar disorder, manic." The MTP dated 7/7/15 listed only nursing staff initials for the nursing staff responsible for providing care to the patient.

2. Patient B3 was admitted on 7/9/15 with a diagnosis of "Substance use disorder (opiates and benzodiazepines), likely withdrawal from both currently; Major depression by history." The MTP dated 7/9/15 listed only nursing staff initials for the nursing staff responsible for providing care to the patient.

3. Patient B4 was admitted on 7/10/15 with a diagnosis of "Mood D/O [Disorder] NOS; Psychosis NOS; R/O [rule Out] Dementia." The MTP dated 7/10/15 listed only nursing staff initials for the nursing staff responsible for providing care to the patient.

B. Interview

In an interview on 7/28/15 at 10:30 AM, the COO [also functioning as the Director of Nursing] concurred that MTPs did not consistently list nursing staff responsible for treatment interventions and did not specifically identify nursing staff name and discipline.

Based on observations, interviews and record review, the facility failed to provide adequate numbers of registered nurses (RNs) to ensure that a RN was consistently available on Unit A to provide care to patients and to direct and supervise the non-professional nursing personnel. This failure places non-licensed staff in the position of providing care that should be supervised by a RN and creates potential safety concerns for the patients.

Findings include:

A. Observations

1. Observations on Unit A on 7/27/15 at 11:40 AM revealed that only MHAs were on the locked ward with 14 patients. Patient A4 was knocking on a door at the far end of the hallway. The Chief Operating Officer, who was with the surveyors, stated that Patient A4 was knocking on the "nursing station" door. The nursing station was designed like a patient room and had a solid door that was closed. Patient A4 stated, "She's [RN] not here. I've been knocking on the door for two hours."

2. Observation on Unit A on 7/27/15 at 2:30 PM revealed that only MHAs were on the locked ward with 14 patients. Several patients were standing at the end of the hallway, looking out the glass. RN1, who was the assigned nurse, was outside smoking. Patient A4, who was watching her smoke stated, "She's been out there a long time and she [pointing to a patient standing next to him/her] is waiting on her paperwork so that she can go home." The patient acknowledged that she was being discharged, that her ride was there but the nurse had not finished her paperwork. RN1 returned to the unit at 2:50 PM.

3. Observation on Unit A on 7/28/15 at 9:15 AM revealed no staff on the unit. Two patients, C1 and C2, were on the unit unattended. RN4, who was assigned to Unit A, was in a Treatment Team meeting that had started at 8:30 AM.

Staff Interviews

1. In interview on 7/27/15 at 11:40 AM, MHA1 stated that RN1 (RN assigned to Unit A) was "On the other side [Unit B] doing an intake." In order to get from Unit A to Unit B, staff had to go through two (2) locked doors.

2. In interview on 7/27/15 at 11:55 AM, RN1 stated that she had been off the unit for almost two (2) hours doing a new patient interview for a patient admitted to Unit B. She stated that new admission intakes were rotated among the RNs assigned and that it was her turn to admit. Admissions intakes were always completed on Unit B. When asked if a RN replaced her when she was off the unit, RN1 stated, "No". She stated that she was off the unit for lunch, breaks and to go to the bathroom. (There was no staff bathroom on Unit A) When asked if there was ever a time when only one staff member was on the unit, RN1 stated, "Yes". She also voiced concern for the safety of staff since there were no alarms on the unit and staff would have to "go off the unit" to get help. RN1 stated that it was very important for the staff on the unit to communicate when they were going to be off the unit.

3. In interview on 7/27/15 at 2:45 PM, MHA1, when asked about RN1, stated "I guess she's on the other side." [RN1 was outside smoking]

4. In interview on 7/28/15 at 9:25 AM, the Unit Director stated that it was possible that at times only one staff member could be on the unit. She added that someone was always sitting at the window of the nursing station on Unit B and could see if something appeared wrong on Unit A. Observation of the window on 7/28/15 at 9:25 AM revealed that no one was sitting at that spot in the nursing station.

5. In interview on 7/28/15 at 9:40 AM, MHA3 stated that sometimes the RN goes off the unit to get medications from Unit B, to go to lunch and to go to the bathroom. She stated that she could be on the unit by herself at times.

C. Record Review

1. A review of the Inpatient Admissions Log for 7/01/15-7/28/15 revealed that 75 patients had been admitted. The total RN staffing numbers presented by the Director of Nursing showed that three (3) RNs were usually assigned for Units A and B. Since new admissions were rotated among RNs, the RN assigned to Unit A during this time period could have been off the unit doing new patient intakes at least 25 times.

Based on record review and staff interview it was determined that the facility failed to provide professional therapeutic staff that would design and implement structured therapeutic activities. This failure results in a lack of structured therapeutic groups/activities to assist the patient in meeting their treatment goals.

Findings include:

A. Record review
A review of the unit activity schedule for Units A and B revealed that groups run by activity therapy staff were held daily from Monday-Friday but were not conducted on week-ends. The only activities provided on week-ends (except for two social work groups) were provided by Mental Health Associates.

B. Interview

1. In interview on 7/28/15 at 11:55 AM, Recreation Therapist 1(RT1) stated that she worked Monday-Friday and that any RT programming on week-end was done by nursing staff.

2. In interview on 7/8/15 at 11:55 AM, the Clinical Services Director stated that RT1 was only half-time in the hospital and that there was no Activity Therapy coverage on week-ends.

On 08/10/2015 at 2:15 p.m., observations during a tour of the physical environment showed a 16 French Foley catheter out of the package and a 60 ml (milliliter) syringe lying on the back of the patient bathroom sink in room 101. Further investigation with the RN 3 revealed the patient in room 101 was using the catheter for self catheterization irrigations. RN 3 stated the patient should be using a new sterile catheter each time and placing the old ones in a biohazard bag each time. RN 3 verified the finding on 08/10/2015 at 2:30 p.m.



31395

Based on observations, interview, and review of the hospital's policies and procedures, the hospital failed to ensure that 1 of 3 Registered Nurses (RN 1) observed during medication administration performed hand hygiene between patients according to accepted principles of infection control and the hospital's policies and procedures (RN 1) and failed to ensure patient equipment was maintained in it packaging until use. (Foley Catheter)

The findings are:

On 08/11/15 at 2:05 p.m., observations of Registered Nurse(RN) 1 during the medication administration task revealed RN 1 administered the medication to 4 different patients and performed hand hygiene between patients, but only washed his/her hands for 7 - 10 seconds each time. RN 1 failed to perform adequate hand washing. On 08/11/15 at 2:25 p.m., RN 1 revealed, "I did not wash my hands long enough. I should have washed for 15 seconds. Normally I use the hand sanitizer".
Hospital Policy and Procedure, titled, "Hand Hygiene", reads, "....3. Hand-hygiene technique....B. When washing hand with soap and water, wet hands first with water, apply and apply amount of product recommended by the manufacturer to hands, and rubhands together vigorously for a least 20 seconds, covering all surfacces of the hands and fingers....".