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Based on medical record review, document and policy review and staff interview, it was determined that the hospital failed to ensure the quality assessment and performance improvement (QAPI) program conducted an analysis of 3 of 3 adverse medication contraband events and implemented preventive actions. Findings included:

The hospital policy entitled "Clinical Risk Safety Program" stated, "...The Clinical Risk Safety Program, involves proactively identifying potential and actual risks to safety, identifying underlying causes, and making necessary improvements to reduce the risk...coordinated by the Performance Improvement Administrator...Program are addressed through...performance improvement teams...medication safety...Information regarding the event is documented and forwarded to the appropriate hospital staff for review and further action as indicated...review and action ranges from monitoring...(to)....processes to proactive risk assessments..."

The hospital policy entitled "Management of the Environment of Care" stated, " ...Contraband ...Examples include but are not limited to...drugs, narcotics...unauthorized chemicals..."

The hospital policy entitled "Administration of Drugs: General" stated, "...Observe the patient take the drug. Stay with the patient until he/she has swallowed the drug..."

A. Review of hospital event documentation revealed 3 adverse medication contraband events occurred as follows:

1. 2/26/17 (7:30 PM - 8:15 PM):
a. Unit Kent 3: Patient #13 reported to have ingested pill received from patient on Unit Sussex 1.
b. Unit Sussex 1: 2 patient rooms searched. Pill was found in Patient #5's room and confiscated. Reported as "no injury...nothing physically wrong with them".

2. 3/6/17 (8:00 AM - 8:35 AM):
Nurse observed Patient #14 "hand passing off" to Patient #6 in the dining room. 1 pill (Clonazepam) was confiscated from the patients; both patient's rooms were searched. Two medications, Seroquel (100 mg) and Wellbutrin (150 mg), were confiscated when found in Patient #6's room (Unit Sussex 1). No contraband was found in Patient #14's room.

3. 4/14/17 - Unit Kent 2 (8:00 AM)
Patient #1 reported to the medication nurse that he/she had "...taken 20 pills...I want to kill myself. Maybe I need to go to the hospital."

B. Hospital document entitled "Investigative Report", dated 4/17/17, documented that on 4/14/17 at 8:00 AM, Patient #1 went to the medication room and stated to the nurse that he/she took 20 pills (of Thorazine) as a suicide attempt and should be taken to the hospital. The patient was transported to a local hospital's emergency room for further evaluation; a room search was conducted and "30 half-digested various types of pills were found". The patient returned to Delaware Psychiatric Center on 4/14/17 at 3:50 PM with discharge paperwork indicating that "no significant abnormalities were noted".

C. No evidence that the QAPI program conducted an analysis of the adverse medication contraband events to analyze the causes.

During an interview on 5/22/17 at 4:35 PM, Performance Improvement Director A reported that a plan was created to address the adverse medication contraband events in March 2017; however, the "Start Date" for the plan's preliminary analysis was not until 5/29/17.

Based on review of quality assessment and performance improvement (QAPI) documentation, policy review and staff interview, it was determined that the hospital's governing body failed to ensure that there was a determination of the number of distinct QAPI improvement projects conducted annually. Findings included:

The hospital policy entitled "Clinical Risk Safety Program" stated, "...At least annually, the Performance Improvement Department conducts a self evaluation of the effectiveness (sic) and reports to the Governing Authority what system or process failures have occurred and the actions taken to improve safety, both proactively and in response to actual occurrences..."

The "Delaware Performance Improvement Steering Committee Charter" stated, "The...Performance Improvement Steering Committee ('Committee') is an oversight group...advisory to the DPC (Delaware Psychiatric Center) Chief Executive Officer ...and the DPC Governing Authority...The Committee Chair shall provide an annual report to the DPC Chief Executive Officer and Governing Authority by January 31st summarizing Performance Improvement activities of the PI (Performance Improvement) Department for the previous year...shall maintain minutes of all its meetings to document its activities and recommendations...Advisory responsibilities:...Recommending, monitoring and overseeing reviews, and developing and implementing improvement plans..."

The document dated 5/8/17 and entitled "Proposal for PI Steering Committee Meeting Content 2017" stated, "...Preliminary reports will be sent out two weeks in advance of PI Steering Meeting..."

A. On 5/19/17 at 1:15 PM, PI Director A stated that the plan approval for the QAPI program was scheduled for the following week and that he/she would provide evidence of prior annual meetings.

B. Review of documentation provided by Deputy Director A and PI Director A revealed packets entitled "Departmental Performance Measures...For the Performance Improvement Steering Committee" each containing subtitles and dates as follows:

- "Post Meeting Packet Sent on December 4th, 2015"
- "Pre-Meeting Packet Sent on February 10th, 2016"
- "Presented and Approved on February 16th, 2016"

Each packet documented performance measures, justification for performance measures, goals, tracking and monitoring data, and conclusions related to goals met and not met.

C. No evidence that an annual review of PI projects was performed since February 2016.

D. On 5/22/17 at 3:30 PM, Deputy Director A confirmed that February 2016 was the most recent annual PI review, and that the next review was scheduled for the upcoming week.

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 3 of 6 patients (Patient #'s 3, 4 and 5) the sample. Findings included:

The hospital policy entitled "Nursing Assignments" stated, "...registered nurse shall be assigned to each client area, each shift and have the full responsibility for overseeing nursing care on that shift..."

The hospital policy entitled "Ongoing Nutrition Assessment" stated, "...Registered Dietician...fulfills nutritional consults within 72 hours of receipt and documents in the progress notes...participates in the treatment planning as needed..."

The hospital policy entitled "Client Management Section 4: Client Face Checks, Rounds and Escorting Clients off Unit" stated, "...The staff person assigned to the face check...is to visualize every client, including all clients on 1:1 observation, to observe their physical and mental condition and ensure their well-being and safety. This should be done for every client every 15 minutes...Document the exact time of the individual face check..."

The hospital policy entitled "Charting Progress Notes" stated, "...A Licensed Nurse must write a progress note on every shift in the following instances...on all patients on suicide prevention measures or escape measures..."

The hospital policy entitled "Seclusion or Restraint" stated, "...Physical Hold for forced Medication - The application of force to physically hold a patient...Complete the Seclusion or Restraint Nursing Assessment form..."

Medical record review revealed:

A. Patient #3

1. 4/28/17 1:15 AM "Event Report" documented: "evaluated by Dr (doctor)...not eating or drinking...Client continues to refuse to eat. Vital signs taken. Transfer to ER (emergency room)..."

2 "Facesheet" documented that the patient was transferred to a local hospital on 4/28/17 for hypernatremia (high sodium levels)

3. 5/5/17 12:00 PM "Admission Referral" section entitled "Nurse transfer report" documented: patient was transferred back to Delaware Psychiatric Center (DPC) after hospital admission for "...high sodium levels...now resolved...still refusing to eat..."

4. "Doctor's Order Sheet" dated 5/5/17 included the following physician orders:
a. regular diet with special instructions to encourage patient "intake with foods and liquids...double portions allowed...allow...family to bring...meals..."
b. "Consults...Nutrition: Patient is non-compliant with PO (by mouth) intake"
c. "Special Instructions: Please encourage PO intake"
d. "Nursing...1:1 w (with)/eyesight with no privacy in the bathroom due to bizarre behavior and safety to self"

5. 5/5/17 "Comprehensive Treatment Plan" documented:
- "...Goal...will maintain an adequate nutritional status...will be free from weight loss and abnormal labs...Interventions...Consult Dietician for proper diet and supplement recommendations. Offer double portions daily and document acceptance percentage of meals consumed...Staff Responsible...RN or designee..."

6. "Progress Note" review revealed the patient's blood sugar/glucose levels were low and were reported to the physician on:
5/10/17 6:34 - 7:15 AM: "blood sugar was 74"
5/11/17 7:00 AM: "low blood sugar...69"
5/12/17 6:52 AM: "blood sugar low"

7. No evidence to support that:
a. the ordered nutritional consult was completed between order date of 5/5/17 through date of record review on 5/22/17
b. the registered dietitian saw the patient or participated in treatment planning
c. the nurse identified or followed up when the nutritional consult order was not implemented

8. Review of "Special Precautions Flow Sheets" revealed:
a. Instructions for staff to "...Note the client's location and activities...and evidence that the staff...assess his/her status during the 15 minutes..."
b. No documented evidence to support that 1:1 supervision was completed or documented every 15 minutes during the following dates/time periods:
5/10/17: 7:00 AM - 2:45 PM (7.75 hours)
5/12/17: 3:00 PM - 11:59 PM (9 hours)
5/13/17: 12:00 AM - 11:59 PM (24 hours)
5/14/17: 12:00 AM - 11:59 PM (24 hours)
5/15/17: 12:00 AM - 11:59 PM (24 hours)

These findings were confirmed by Associate Director of Nursing A on 5/22/17 at 2:30 PM.

B. Patient #4

1. "Admission Orders" dated 3/21/17 at 1:30 PM:
- 1:1 with 2 arm's length

2. Review of "Special Support Precautions Flow Sheet" revealed no documentation of every 15 minute checks on the following dates:
5/9/17: 11-7 shift
5/10/17: 11-7 and 3-11 shifts
5/11/17: 11-7 and 3-11 shifts
5/12/17 and 5/13/17: all shifts
5/14/17: 7-3 PM
5/15/17: 11-7 and 3-11 shifts
5/16/17: 11-7 shift
5/17/17: 11-7 shift
5/18/17 and 5/19/17: all shifts

This finding was confirmed by Associate Director of Nursing A on 5/22/17 at 4:12 PM.

C. Patient #5

1. The "Doctor's Order Sheet" contained the following orders:

a. 4/18/17 at 7:55 PM:
- physical hold applied for 2 minutes to administer IM (intramuscular) medication

b. 5/12/17 at 4:35 PM:
- Suicide Precautions
- start patient on 2:1 observation at 1 arm's length secondary to suicide attempt

c. 5/12/17 at 6:45 PM:
- discontinue previous 2:1 observation
- start 1:1 observation at 1 arm's length with no privacy for safety of self due to suicidal attempt

d. 5/13/17 at 8:05 AM:
- continue 1:1 observation at 1 arm's length with no privacy for safety of self due to suicidal attempt
- continue suicidal precautions as previously written for 24 hours

2. No evidence that a:
- "Seclusion or Restraint Nursing Assessment" form was completed after the initiation of the physical hold on 4/18/17 at 7:55 PM
- progress note was written by a licensed nurse for every shift on 5/12 and 5/13/17 after the suicide precautions were initiated

These findings were confirmed by Associate Director of Nursing A on 5/22/17 between 3:10 PM and 3:15 PM.

Based on review of documents, policy review and staff interview, it was determined that for 1 of 1 pharmacy areas where refrigerated medications were stored, staff failed to check and document temperatures to ensure the safety and well-being of patients. Findings included:

The hospital policy entitled "Care Patients (Medication Use-Storage)" stated, "...Biologicals and thermolabile drugs that require refrigeration or freezing shall be stored in a refrigerator or freezer that is capable of maintaining the necessary temperature...Refrigerator and freezer temperatures in patient care areas shall be monitored and recorded daily..."

On 5/19/17 at 11:56 AM, review of "Medication Refrigerator Temperature" logs dated between January 2017 and May 2017 revealed temperatures were not monitored and recorded daily as required.

Interview with Pharmacy Director A on 5/22/17 at 1:42 PM confirmed this finding.

Based on observation, policy review and staff interview, it was determined that for 72 of 72 patients on 5/18/17, the hospital failed to ensure that facilities, supplies and equipment were maintained to ensure an acceptable level of safety, quality and cleanliness. Findings included:

The hospital policy entitled "Maintenance of the Hospital Environment" stated, "...Ensuring a safe sanitary environment for clients and staff is a collaborative effort and is the responsibility of all staff members regardless of title...Housekeeping provides cleaning and disinfecting for the treatment unit environment...This includes daily routine maintenance...to maintain acceptable aesthetic conditions...Specific areas include but are not limited to: table and counter surfaces, vents, ceiling dust, floors and doors, carpet, bathroom and treatment room fixtures such as toilets, sinks, tubs and shower..."

The hospital policy entitled "Resident Room Cleaning" stated,"...high and low dust all light fixtures, windowsills, vents...clean sink, tub and toilet in bathroom. Wash walls behind and under sink and toilet..."

The hospital policy entitled "Cleaning of Drinking Fountains" stated," Drinking fountains are cleaned daily to prevent bacterial growth and to maintain an aesthetic environment..."

The hospital policy entitled "Sinks" stated,"...clean sinks daily to control bacteria and maintain acceptable aesthetic conditions..."

The hospital document entitled "Environmental Rounds Checklist" stated, "...Mattresses, pillows in good repair...Walls are clean and free of stains...Ventilation system operational and adequate (indicated by absence of musty, moldy or foul odors)...Shower areas are clean...Tub areas are clean...Ceiling vents free of dirt and/or dust, corrosion, rust...Floors and walls clean and in good repair...All cabinets are clean and free of dust/rust/stains ...Wall/floor/ceilings clean/free of dust/dirt/stains..."

A. During a Kent 3 Unit tour on 5/18/17 between 10:03 AM and 10:55 AM with Management Analyst A, the following was observed and confirmed at the time of discovery:

1. Maintenance Closet #47A
- rusty electric boxes and pipes
- pipe leakage

2. Male Restroom #46
- 4 dirty air vents
- strong urine odor in 2 of the shower stalls
- dirty bathtub with brown stain on edges

3. Patient Room #43
- dirty air vent

4. Pod A Day Room
- broken ceiling tile
- 2 dusty air vents

5. Patient Room #41
- dusty air vent
- holes in the wall

6. Storage Room #39
- dust hanging from ceiling tiles outside of the door

7. Medication Room #35
- unsealed open space around incoming ceiling pipe (open space filled with a towel)
- bubbled paint with brown stain on the back wall

8. Female Bathroom
- 4 dusty dirty air vents
- dirty sink
- holes in the wall

9. Patient Room #23
- holes in the wall
- metal closet with sharp edges

10. Patient Room #27
- dirty floor

11. Pod B Day Room
- broken ceiling beam

B. During a Kent 2 Unit tour on 5/18/17 between 11:03 AM and 11:40 AM with Management Analyst A, the following was observed and confirmed at the time of discovery:

1. Closet #47A
- rusty electric boxes with pipes going to ceiling

2. Staff Bathroom #47
- missing ceiling tile

3. Patient Room #43
- torn mattress

4. Pod A Day Room
- 2 dusty air vents
- broken ceiling beam

5. Patient Room #27
- trash on the floor
- holes in the wall

6. Patient Room #2
- rusted metal closet
- dusty and dirty closet

7. Female Restroom #46
- 4 dusty air vents
- toilet base caulking stained with brown color
- 2 dirty shower walls
- holes in the wall

8. Male Restroom #31
- 2 dirty shower walls
- strong odor

C. During Sussex 1 Unit tour on 5/18/17 between 11:54 AM and 12:05 PM with Management Analyst A, the following was observed and confirmed at the time of discovery:

1. Laundry Room #19
- dirty sink

2. Patient Room #27
- holes in the floor

3. Male Restroom Pod A
- puddle of water in the shower area
- strong odor
- shower walls stained with brownish color
- rusty air vent
- rusty toilet base

4. Male Restroom Pod B
- dirty shower walls

5. Room #38
- dirty floor
- strong odor

6. Hallway
- dirty water fountain

D. During a Sussex 2 Unit tour on 5/18/17 between 12:14 PM and 12:23 PM with Management Analyst A, the following was observed and confirmed at the time of discovery:

1. Female Restroom next to Supply Room #45
- stained shower walls
- stained toilet bowls

2. Hallway
- dead bugs in the ceiling light