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Based on observations, staff interviews, and review of procedures it was determined the facility did not comply with requirements for the protection and promotion of patients' rights as required.

The facility failed to meet the Condition of Participation for Patient Rights due to non-compliance with requirements as follows:


1. The facility did not consistently comply with requirements for the provision and explanation of information to patients or their representatives about Patient's Rights. This includes the lack of provision of patients' rights documents, including notification of the Important Message from Medicare and Advanced Directives information.
Refer to Tag # A117.


2. The hospital's Grievance Committee did not effectively review and resolve grievances nor ensure the provision of prompt written responses. The facility did not effectively monitor the grievance process . Refer to tag #A119.

3. The facility did not ensure patient participation in treatment and care plans and did not develop treatment plans that met patients' relevant psychological and medical needs. Refer to tag# A130.

4. The facility failed to ensure the provision of a safe environment for patients at risk for falls. Refer to tag #A144.

Based on interview, and review of medical records and Patient Information Handbook, it was determined that the facility did not effectively inform patients, or when appropriate, patient representatives , of patient's rights, in advance of furnishing or discontinuing patient care whenever possible. This deficiency was noted in eight of eight applicable medical records reviewed (MR #s 6, 7, 8, 13, 9, 10, 11 and 12).

Findings include:

1. The facility failed to ensure distribution of patients' rights documents, including the Important Message from Medicare notification and Advanced Directives information. Regulations at 42 CFR 489.27 require that Medicare beneficiaries (or their representatives) receive standardized notices of the 'Important Message from Medicare (IM) within 2 days of admission and that a follow up IM be provided not more than two calendar days before patient discharge.

2. The Director of Social Work was interviewed on 5/29/2013 at 11:01 AM. This staff reported that the Social worker, on the unit, is responsible to ensure that each patient is informed of his/her Patient Rights.

3. The Patient Information Handbook was reviewed on 5/29/2013 at approximately 12:00 PM. It was noted that this handbook did not include the distribution of "An Important Message from Medicare (IM) " form to patients/patients ' representatives.

4. Eight of eight medical records reviewed on 5/30/13 did not demonstrate compliance with distribution of patient rights information, including but not limited to, provision of the initial or follow up notification of the "Important Message from Medicare (IM)". In addition, there was insufficient evidence in records to support that patients or their representatives were informed or educated about Patient's rights requirements.

Examples include:

a. MR #6 was reviewed on 5/30/13 at 11:07 am; this patient was a 68 year old nursing home resident with history of hypertension, breast cancer, schizoaffective D/ O and Bipolar D/O. The patient was sent to the hospital after she threatened to kill staff. The patient was admitted to the hospital on 5/13/13 due to aggressive behavior.
The Psycho-Social Database form, dated 5/14/13, was reviewed. The social worker documented on this form that the patient was confused and unable to provide history. Therefore, the patient ' s son was contacted. It was noted that the form titled, "Status-Advance Directives" dated 5/14/13 at 12:00 PM indicated that the patient was given written information regarding the right to make medical care decisions and to formulate Advance Directives. There was no documentation of follow-up with the patient to ensure that she understood the rights listed in this booklet.
It was also noted that a copy of An Important Message from Medicare (IM) form was located in the record, but this form was not signed. It was noted that, although it was documented in the record that the patient's son was involved in her care, this patient rights information was not presented to this patient's representative.

b. MR #7 was reviewed on 5/30/13 at approximately 11:45 AM; this 72 year old patient had a history of Depression and Dementia and was admitted to the facility from home on 4/10/2013 for depression with psychosis rule out dementia.
The Psycho-Social Database form dated 4/11/13 at 3:00 PM indicated that on admission and during the interview with the social worker, the patient was very confused. It was noted on the "Status-Advance Directives" form dated 4/11/13, that "the patient was unable to consider material on Advance Directives during the screening."
It was noted that the copy of An Important Message from Medicare (IM), form indicated that the patient "refused to sign". This form was not dated or timed. It was documented that the patient's daughter was contacted and she was involved in the discharge plan. There was no documentation that this IM form was presented to the patient's daughter nor documentation to explain why this was not necessary. The patient was discharged on 5/29/13 and there was no documentation that the follow up second IM notification was presented to the patient or her representative.

Similar findings related to the lack of the distribution of required initial or follow up Important Message from Medicare Notices (IM's) were also noted in MR #s 8,9,10,11,12 and 13.

Based on staff interview and review of medical record, policy, and other documents, it was determined that the hospital's Grievance Committee did not effectively review and resolve grievances.

Findings include:

The facility did not establish an effective process for resolution of grievances as follows:

1. The Director of Patient Relations was interviewed on 5/29/13 at 11:10 AM. This staff reported that complaints from patients/patients' representatives are handled by the Patient Relations Department. She also stated that, at the time of admission, a patient is given a copy of the Patient Information Handbook. According to the Director of Patient Relations, the handbook explains how to file a complaint. In regards to grievances, she stated that grievances are handled by the Grievance Committee. According to the Director of Patient Relations, the Grievance Committee is comprised of the following members: Medical Director, Assistant Administrator and the Director of Nursing. She also stated that the Grievance Committee meets on a case per case basis.

2. The Grievance Committee reports and minutes, for 2012 and 2013 were requested to the Director of Patient Relations on 5/29/2013. As of 5/31/13, this information was not provided.

3. The hospital did not implement a process for the provision of timely written responses to grievances. The Patient Information Handbook was reviewed on 5/29/13. According to the facility's Patient Information Handbook, " the hospital established a Grievance Committee to review and resolve grievance." It was noted that the time frame for the resolution of a grievance and the provision of the grievance shall be no longer that 3 business days from the time the grievance was submitted to the committee. However, the time frame for the provision of a written response to the complainant was not stated.

4. The policy titled, " Rights and Responsibility of the Individual - reference R1.01.07.01", (Grievance Policy) was reviewed on 5/29/13. This policy indicated that "all complaints shall be referred to the Patient Representative." "If the nature of the complaint is such that it cannot be resolved by the Director of Patient Relations, the complaint shall be deemed a grievance and shall be forward to the appropriate members of the Grievance Committee." This policy and process did not include the following:

a. A written complaint is always considered a grievance.

b. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances.

c. Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance, or when the patient requests a response from the hospital, the complaint is considered a grievance.

5. The following patient grievance reviewed on 5/30/13 did not include evidence of a complete investigation or provision of a response to the complainant.

The Patient Relations Department: "Patient Complaint/Concern Report form", dated 12/11/12, for Patient # 14 was reviewed on 5/30/13. Review of this Grievance noted that the patient's (in MR # 14) sister filed a written complaint with the facility regarding the facility's failure to notify her that her brother was transferred to another Hospital. It was noted that the complainant requested an investigation.

It was noted that the investigation found that an attempt was made to contact the sister, but the telephone number listed for the sister was incorrect. It was noted that the date and time the grievance was investigated and the staff/department that investigated this issue was not documented. This patient's representative was not provided a written response on the outcome of the investigation.

Review of MR #14 on 5/31/13 noted that this 73 year old patient, with history of Dementia, Hypertension and Cardiac Disease, had a seizure in the unit and he was sent to a Hospital on 12/8/12. There was no documentation in the record that the patient ' s representative was contacted. It was noted that a copy of Health Care Proxy Form was located in the record. It was noted that the sister was listed as the patient ' s health agent. It was noted that the telephone number listed on the Health Care Proxy form was the same number as listed on the complaint document.

Based on the review of medical records, it was determined that the facility did not effectively ensure participation by patients and/or patient representatives in the development and implementation of patients' treatment/care plans or that treatment plans met the patients' psychological and medical needs.
This deficiency was noted in two of eight applicable medical records reviewed (MR #s 15 and 16).

Findings include:

1. Review of MR #15 on 5/31/13 at approximately 11:00 AM, noted that this patient, a 69 year old adult home resident with history of DM, HTN, GERD and schizoaffective Disorder. The patient was admitted to the hospital on 3/5/13 on a voluntary status, due to being "sexually preoccupied, engaging in inappropriate behavior with male residents, urinating in public and in the hallways and consuming ETOH."

The Multidisciplinary Treatment Plan dated 3/7/13 was reviewed on 5/31/13. It was noted that the identified problems, on the treatment plan were "behavior disturbance and medical." It was documented that the patient's anticipated services, prior to discharge, were medication management and supportive therapy. It was noted that treatment plan was signed by the staff. It noted that there was a section on the Multidisciplinary Treatment Plan form for the patient to sign and it was noted that on the form that the patient "refused to sign." The reason for the patient's objection to the treatment plan was not documented. It was noted that the treatment plan did not address the patient's alcohol consumption.
Review of Nursing Admission Assessment dated 3/5/13 noted that the patient had no learning barriers. It was also noted that the Psycho-Social Database form dated 3/6/13 indicated that the patient was able to contribute to and provide information regarding her history.

2. Review of MR # 16, on 5/30/13, noted that this 26 year old homeless male with history of schizoaffective D/O and Poly Substance Dependence and was admitted on 1/15/13. It was noted that the patient went to the facility due to depression, paranoia, and getting into arguments with people in the shelter.
It was noted that on 2/23/13 at 1:00 PM the staff found the patient in front of a female's bedroom door; he exposed self and masturbated in front of a female patient.
It was noted that the Multidisciplinary Treatment Plan , dated 1/17/13, listed the problem/issues to be addressed as: Schizoaffective D/O, Poly-substance Dependence and Medical. The patient's inappropriate sexual behavior was not addressed and there was no documentation in the record that the patient's Multidisciplinary Treatment Plan was updated in order to incorporate this behavior.

Based on staff interviews, review of medical records and policies and procedures, it was determined that the facility failed to ensure that patients at risk for falls are provided care in a safe setting. Specifically, the Hospital failed to provide close supervision of two patients (MR#s 4 and 5).

Findings include:

Review of two (2) medical records on 5/30/13 at 11:55 AM noted that these patients were identified at risk for fall on admission and placed on the hospital Fall Prevention Program and close observation status. These two patients, who were both at risk for fall and assigned to close observation, were not closely observed by nursing staff.

Review of MR #4 on 5/30/13, noted this 70 year old confused female patient who was admitted to the hospital on 5/15/13. The patient was assessed on admission by nursing staff to be at risk for falls. It was noted that the nursing staff documented loss of balance while standing and mandatory assistance when ambulating on the Fall Prevention Program. It was also noted that the patient uses a wheelchair. The patient was assigned to close observation level.

On 5/21/12 nursing noted at 2:15 PM that patient slipped and fell at 1:30 PM. The nursing staff noted that patient was found lying on the left side on the floor leaning against the door of the day room. The nurse noted that the patient stated she bumped the left side of her head and both knees. This patient was seen and evaluated by the physician and sent to another area hospital for CT-scan of the head for further assessment.

2- Medical Record #5, reviewed on 5/30/13, references a 71 year old male patient with history of dementia and Alzheimer who was admitted to the hospital on 5/28/13. The patient was assessed on admission to be at risk for falls. Nursing documented on the Fall Prevention Program sheet the loss of balance while standing and the patient's gait pattern changed when walking through doorway. It was noted that patient uses a wheelchair. The patient was assigned to close observation level.

A nursing note, dated 5/29/13 at 7:00 PM, documented that the patient was lying on his right side on the floor in the dining room and that the patient stated he got up from his wheelchair, walked, and fell. The nurse documented no loss of consciousness noted, the patient denied dizziness, and right side of face was noted to be red.

Post fall documentation noted in both medical records indicated that both patients self-reported their falls to nursing staff.
For example, post fall documentation recorded by nursing staff indicated that MR #4 was found lying on the floor in the day room and MR #5 was on the floor of the dining room. This documentation indicates that fall incidents were reported to nursing staff by the patient's themselves. This post fall documentation therefore shows that both falls were not witnessed by nursing staff, even though both patients were on close observation.

During an interview on 5/31/13 with the Director of Nursing and the Assistant Director of Nursing, the Assistant Director of Nursing stated that 1:1 is used for patients who are suicidal and that patients who are at risk for fall are placed on close observation. He stated that close observation means that the staff (observer) must be able to eyeball the patient they are observing.

The Close Observation policy was requested from Nursing staff on 5/31/13, but this policy was not provided to the survey team.

Based on interview and review of the hospital's Quality Improvement Program, it was determined that the facility failed to develop and implement an action plan to correct the problems identified in the Pharmacy Department Quality Improvement measures. Specifically, the facility failed to develop corrective actions for dispensing errors identified by the Pharmacy. This failed practice was evident in each quarter of 2012. Additionally, it was determined that the facility failed to develop a process for the identification of environmental hazards in the hospital and implement through established mechanisms, of actions necessary to correct the identified problems.

Finding 1

1-On 05/30/2013, review of the minutes from the Hospital Quality Council Meeting, held March 27, 2013, and the Executive Summary Quality Improvement Report, Fourth Quarter 2012, noted the Medical Director's reported on Dispensing Errors. There were 7 Dispensing Errors by the Pharmacy Department for the Fourth Quarter, October - December, 2012. The Error Types were (a) 4 Wrong Dose (b) 1 Omission (c) 2 Wrong Medication. Six of these seven errors resulted from the order entry made by the Pharmacist. The report indicated that dispensing errors had increased from 3 to 7.

Similar Dispensing Errors were reported by the pharmacy for the prior three quarters in 2012. A review of the reports on Dispensing Errors for each quarter noted there were 12 Dispensing Errors for the First Quarter, 2012; 12 Dispensing Errors Second Quarter, 2012 and 3 Dispensing Errors Third Quarter, 2012. Each dispensing error was reviewed and it was noted that the highest number of errors were "Order entry by pharmacist."

In an Interview on 05/31/2013 at 9:30am, the Director of Pharmacy acknowledged the dispensing error reports and stated that the errors and the process were reviewed to identify any break in the process and or areas for improvement. All errors were reviewed with the staff involved but there is no written plan for correction.

A written corrective action plan has not been developed and implemented to correct the problems identified in the pharmacy department.


Finding 2
Review of the "Environment of Care Indicators" for the 2nd quarter of 2012, noted that one safety hazard was identified in the minutes. Similarly one safety hazard was identified for the first and second quarter of 2012. No description was documented regarding what kind of safety hazards were identified.

At interview with the Director of Engineering on 5/30/13 at 11:30 AM, he stated there was no detail documentation of the safety hazard found in each quarter and he was unable to provide a description of the safety hazards identified and the courses of actions taken to address the problems.

However, on tour of the facility on 5/28, 5/30 and 5/31/13, multiple safety hazards were identified. Cross- refer to specific findings noted under 482.41 (a) Maintenance of Physical Plant, Tag # A701.

Based on staff interviews, review of hospital's policy, Incident reports, and Quality Improvement Program Reports, it was determined that the hospital did not administer its Quality Assurance (QA) Program to identify opportunities for improvement in the management of incidents of patients' violent or sexual behavior, or the effectiveness of oversight of Grievances and Discharge planning processes.

Findings include:

1. The facility did not identify need for improvement in the management of incidents of patients' violent behavior or sexual contacts and did not take the necessary corrective action to prevent these events. The facility also did not monitor or analyze the effectiveness of the management of Grievances and Discharge Planning.
Findings include:
(a) Incidents of Patients' violent behavior and sexual contacts:
The Facility ' s Administrator submitted the facility ' s " Incident Log " for the year 2012 and the year 2013 on 5/29/13 at approximately 12:30 PM. These documents were reviewed on 5/29/12 at approximately 12:35 PM. The surveyor tallied up the numbers of patients ' violent behavior (such as altercation and assault) and sexual contacts listed on the log. It was noted that there were: 62 aggressive behaviors, 7 patient to patient altercations, and 3 patient to patient sexual behavior/contacts. In the year 2013 (1/13- 4/13) , there were 39 aggressive behavior, 4 patient to patient altercations, 3 patient to patient physical assaults, and 7 patient to patient or inappropriate sexual behavior/ contacts.

A request was made to the Director of Nursing on 5/30/13 for the Departmental Psychiatry/Medical Staff Quality Assurance reports minutes, for the year 2012 and the year 2013. The Meeting (s) of the Medical Staff Minutes were submitted for review on 5/31/13.
Meeting(s) of the Medical Staff Minutes for October 27, 2011, January 30, 2012, October 25, 2012 , and January 29, 2013 were reviewed on 5/31/2013 at 2:00 PM. It was noted that the incidents regarding the patients ' behavior on the units and the actions taken were not discussed in any of these minutes.
Executive Summary Quality Improvement Program report for the Fourth Quarter, October - December 2012, was reviewed, on 5/31/13 at approximately 2:00 PM. It was noted that patient altercations, physical assaults, aggressive behavior and sexual contacts were not discussed or analyzed in this report.
The Quality Improvement Committee Minutes October 10, 2012 indicated that mean monthly number of violent incidents declined by 42% from 4.75 to 2.75 and the number of sex incidents decreased by 45% from .75 to .41. Review of incident log for 2012 and year 2013 (period of 1/13- 4/13) noted that there was an increase in sexual contacts for the year 2013. The facility did not submit its Quality Improvement Plan for the year 2013. Therefore, it was unable to determine how the facility planned to correct and monitor these issues.
The facility's Policy and Procedure for "Protection of Patients - Events Involving Sexual Contact or Possible Sexual Assaults: Rev: 12/12 "was reviewed on 5/30/13. It was determined that the facility did not have an effective sexual contact incident or prevention policy. For example: the policy stated " The patient (s) shall immediately be separated." This language was unclear as it did not specify if the patients are physically separated or transferred to another floor, unit or room. It was also noted that the preventive measures to be implemented were not discussed in this policy. The psychological assessment of patients who are involved in incidents of sexual contact or assault was not included.

(b) Grievances:
The Director of Patient Relations was interviewed on 5/29/2013 at 11:10 AM. According to the Department of Patient Relations, the Grievance Committee meets and resolves grievances.

Copies of Grievance minutes for the year 2012 and 2013 were requested on 5/29/2013. Patient Satisfaction Survey Analysis for 2012 was submitted. Results of Patient Satisfactory Surveys for The Third & Fourth Quarters were reviewed on 5/31/2013 . Regulatory guidelines indicate that information contained the Analysis from Patient Satisfaction Surveys usually do not meet the definition of a grievance unless the patient/patients ' representative writes or attaches a written complaint on the survey and requests resolution . There was no evidence that the information taken from the Patient Satisfaction Surveys reports were obtained from written complaints attached to the satisfaction surveys. Consequently, the facility is substituting data obtained from Patient Satisfaction Surveys as grievance quality review.

According to the Rights and Responsibilities of the Individual Policy, " The Director of Patient Relations shall analyze trends/data and work with all department heads to resolve patients concerns. The Data obtained shall be shared with appropriate departments and the Quality Improvement Committee " . Review of the Executive Summary Quality Improvement Program report - Fourth Quality, October - December 2012 noted that the analyzed data information from the Patient Relations Department was taken from the patient satisfaction questionnaires. Therefore, the facility was not analyzing or tracking patients ' complaints/grievances.

The Department of Patient Relations Patient/Family Grievance logs for 2012 and 2013 were reviewed on 5/29/2013. The logs indicated that there were 19 patient complaints in 2013 and 60 complaints in 2012. It was noted that the majority of complaints were regarding missing property. This data was not included in the report submitted to the Quality Improvement Committee.

(c) Discharge Planning:
The Director of social work was interviewed on 5/29/13 at approximately 11:01 AM. The staff reported that Social Work Department was responsible for Discharge Planning. The Department of Social Work Quality Assurance (QA) reports and minutes for 2012 to present were requested for review.
The Social Work QI Monitoring (January 2012 - March 2013) was submitted on 5/30/13. Review of the Social Work QI Monitoring submitted noted that this department was reviewing 10 medical records each month. It was noted that each medical record was reviewed for the following categories: timely assessment, effective assessment, treatment plan, D/C plan, D/C summary, D/C criteria, Subsequent Provider transmittal and legibility. It was noted that the action plan was " to speak to the SW " .
The Director of Social Worker was re-interviewed on 5/31/13 at 1:35 PM regarding the QI information submitted. The Director of Social Work (SW) reported that he randomly selects 10 medical records each month and the records are reviewed for the selected categories. He also stated that, if there is any deficiency in the record, he meet with the individual social worker to discuss the deficiency. He reported that " there are no monthly meetings only individual supervision " . According to the Director of SW, there are improvements in some areas and other areas need improvement but he was unable to specify the details, as he did not have the necessary data.


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2. Based on interview and review of the minutes of the Quality Improvement Committee Meeting held November 14, 2012, and the Hospital Quality Council Meeting, held March 27, 2013, it was determined that the facility failed to follow its timeline in the development and implementation the hospital- wide Quality Assessment and Performance Improvement Program for 2013.


Findings include:

On 05/30/2013, review of the minutes from Quality Improvement Committee meeting, November 14, 2012, noted that the Chairman will be accepting suggestions for 2013 Cross Organizational Quality Improvement Projects during the first quarter of the year. The minutes from the Hospital Quality Council Meeting, held March 27, 2013 was also reviewed and it was noted that there was no documented follow-up on this project.
At Interview with the Chief Executive Officer On 05/31/2013 at 2:45pm, he stated that the Cross Organizational Projects for 2013 was not developed as stated in the minutes but a meeting will be held next Wednesday to develop the quality improvement projects for 2013.

Based on the review of medical record, it was determined that the facility did not consistently ensure that the nursing staff developed an appropriate care plan for each patient. This deficiency was noted in one of five applicable medical records reviewed (MR # 15)
Findings include:
Review of MR #15, on 5/31/13 at approximately 11:00 ARE, noted that this 69 year old with diagnosis of schizoaffective disorder was admitted to the facility on 3/5/2013.
The Nursing Department Admission Assessment form, dated 3/5/13 at 7:30 AM, was reviewed. It was noted that the nurse documented that the patient had lacerations located on "?elbow, bruises on ? hip (L) breast + ? + (L) hands, both knees " . This assessment was incomplete as the assessment did not include if there was a discussion with the patient regarding how these injuries were sustained.
It was noted that the injuries were not included in the nursing plan of care 3/7/13.

Based on interview, the review of medical records and other document, it was determined that nursing staff did not consistently ensure the implementation of its Intramuscular Medication observation protocol to include the monitoring of vital signs, post administration of intramuscular medication (IM). This finding was noted in 6 of 7 instances where intramuscular medication was administered for two patients.

Findings include:

The facility's policy and procedure titled, Chemical Restraint, indicates in paragraph XII that a trained and competent staff member would assess the patient at the initiation of chemical restraint and every 15 minutes thereafter. This assessment shall include the following: signs of injuries associated with application of chemical restraint; nutrition/hydration status; circulation and range of motion; vital signs; hygiene and elimination; physical and psychological status and comfort and readiness for discontinuation of chemical restraint.


MR # 2 is a 37 year-old female with multiple psychiatric admissions that was admitted on 5/15/13 with the impression of Chronic Paranoid Schizophrenia. The patient received multiple start doses of IM medications during the course of hospitalization to manage her aggressive behavior.
The patient's full vital signs were documented only on one out of the five occasions that IM medications were administered. The patient was noted to have refused vital signs on 5/22/13, 5/23/13, 5/24/13 and 5/25/13; however, there were no indication based on the review the "Post-IM Monitoring Assessment" forms that vital signs were attempted when the patient was to be calmer and less agitated.

Similar findings were noted for patient in MR #3 who received Ativan, (a benzodiazepine), 2mg intramuscular (IM) on 5/22/13 and Zyprexa (an antipsychotic)10mg IM on 5/27/13 for management of agitation. There were no vital signs documented during the post IM assessment period.

At interview with the Head Nurse on the 4th floor inpatient unit on 5/31/13 at 11:45AM, she stated that patients are uncooperative post IM medication administration and often refuse vital signs. The nurse, however, did not address the surveyors concern regarding the prevalence of the lack of vital signs in the 6 of 7 post IM monitoring assessments reviewed.

Based on interview and the review of medical record, it was determined that medications were not administered as prescribed by the physician. Specific reference is made to the lack of appropriate documentation in the Medication Administration Record of medications given to the patient. This finding was noted in 1 of 10 applicable records.

Findings include:

MR # 1 is a 77 year-old female who was admitted to the facility on 3/13/13 for management of psychosis. The patient was noted to be paranoid, disorganized with marked agitation. The review of the patient's Medication Administration Record and physician orders revealed medication orders were not implemented in accordance with the physician orders. There were no indication the patient received the following medications:

On 3/26/13, the physician ordered Vitamin B12 1000 micrograms (mcg) subcutaneously, daily for four days; the medication was administered on 3/26/13 and 3/27/13 only. The reason for not providing the medication on 3/28 and 3/29 was not documented.

On 3/28/13 at 8:00 AM, the physician ordered Cogentin, 1 Milligram (mg) to be taken orally, twice daily. The medical record showed the patient did not receive the 6:00 PM dose on 4/3/13.

Trazodone 150mg at bedtime was ordered on 3/30/13. The 4/3/13 dose was omitted from the medication administration record.

Haldol 4 mg orally BID was ordered on 3/28/13 at 8:00 AM. The 6:00 PM dose was omitted from the medication administration record.


Similarly, medication omissions were noted on the medication administration record.
4/9/13 for the 10:00 AM and 6:00 PM dose of Cogentin 1 mg; the 10:00 PM dose of Trazodone 150mg; the 10:00 AM dose of Hydrochlorothizide 25mg, and the 10:00 AM and 6:00 PM dose of Haldol 4 mg. All omitted medications were active orders.

At interview with the Nursing Director on 5/29/13 at 1:15 PM regarding medication omissions in the patient's record, she acknowledged these findings, but upon further review of the patient's medical record she presented the nurses documentation on 4/9/13 at 11:00 AM that indicated "the patient is calm and accepting medications without side effect." The Director of Nursing stated that the nurse did not implement the medication administration policy that requires medications to be initialed in the MAR following administration.

The facility did not have a process or policy in place to identify and investigate medications that are not initialed as given.

Based on interviews and document review, it was determined that the Hospital did not ensure staff are continually kept informed regarding the hospital's Formulary and did not conduct annual review or update of the formulary in accordance with the hospital' s practice.

Findings include:

The review of Hospital Formulary, presented in a binder on 5/29/13 at 13:00, noted the Hospital Formulary was last reviewed and approved in its entirety on November 4, 2009. Review of the facesheet contained in this hospital formulary binder confirmed the responsibility of the Pharmacy department to update the hospital formulary on an annual basis. A copy of the outdated Hospital Formulary was also found on a shelf during the tour of the Pharmacy Department on 5/29/13 at 15:15 PM.

At interview with the pharmacist on duty on 5/31/13 at 10:30 AM, she stated the Medical Director and the Director of Pharmacy are responsible for reviewing and updating the Hospital Formulary annually and as needed. She added that the pharmacy has an on-line program, "Lexicomp", which permits the access to medication information and formulary; hence the outdated Hospital Formulary binder is never used. This on-line program is only available in the Pharmacy Department and is not accessible to clinical staff in all the inpatient units.

This information was confirmed by interviews of the respective Head Nurses of the 2nd, 3rd, 4th and 5th floors during unit conducted during all dates of the survey on 5/29, 5/30 , and 5/31/13.

At interview with the Director of Pharmacy on 5/31/13 at 10:30 AM, regarding the availability of Lexicomp to all staff, she stated that in addition to the availability of the Physicians' Desk Reference (PDR) on the units, the clinical staff members are aware they can call pharmacy for information regarding formulary medications.

During further discussion on 5/31/13 at 10:30 AM, concerning the lack of regular updates of the Hospital Formulary, the Director of Pharmacy stated she meets with the Medical Director periodically to review the Hospital Formulary, but these reviews are sometimes unofficial through phone contacts and are not documented.

A 2011 committee meeting was presented by the Director of Pharmacy on 5/31/13 at 11:00 AM; the report did not indicate the day and the month the meeting was held. The report shows three medications were added to the Hospital formulary but were not included in the Hospital Formulary binder which is readily available for use by medical personnel on the units.

Based on observation and staff interview, the hospital environment was not maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

During the tour of the facility from 05/29/13 to 05/31/13 between 11:00 AM to 4:00 PM, the following issues were noted, which were verified with the Director of Engineering and other staff accompanying the surveyor.

1. The Soiled Utility rooms on all patient floors did not exhibit negative air pressure. Furthermore, the medication room did not have the required positive air pressure and instead exhibited negative air pressure during a simple tissue test.

2. Intermingling of clean items in dirty rooms were noted in the Janitor closets and in the Morgue. Clean supplies were noted stored in these rooms. Storing of clean items/supplies in dirty rooms leads to cross contamination.

3. The Morgue room was noted having a very dirty/rusty stretcher in the room and the floor was noted dirty and dusty.

4. The oxygen storage room in the basement was noted very dirty and dust and garbage on the floor and under the wooden floor planks.

5. During the tour of the patient units/floors it was noted that perimeters of the floors/unit/rooms were very dusty and dirty. There was accumulation of dust and dirt around corners of the rooms and behind the smoke/fire doors.

6. The log of the refrigerator used for storing beverages for patient in the medication room of the 5th floor indicated that it was out of the required range of 34*F-41*F on many days in the month of May 2013. Most of the days indicated the temperature between 28*F to 33*F. No follow-up or corrective action was taken to ensure that the temperature of the refrigerator is maintained within the acceptable range of the policy and procedure.

7. The refrigerator gasket in the pantry of 5th floor was noted dirty and broken.

8. The mechanical room adjacent to the day-room on 5th floor exhibited thick layer of dust and dirt. This room is situated as such that the dust and dirt will contaminate the day room when air flows or when the door is opened for work/preventive maintenance.

9. The electrical closet on the 3rd floor near the pantry was noted not secured against unauthorized access.

10. During the tour of the facility, loopable hazard in the form of regulator knobs on the heater/air-condition unit was noted throughout the facility including the patient rooms.

11. The grills of the heater/air-condition unit was noted dirty and dusty in many rooms including but not limited to room #426.

12. The upholstery of two to three chairs in the main waiting room/lobby were noted torn and in dis-repair.

13. During the survey it was noted that the seclusion rooms have a window on the door. The 1 hour fire rating of this window could not be verified during survey as required by AIA 1996/97 11. 2.C.

14. During the survey, nursing staff acknowledged using the seclusion room for the purpose of timeout/quiet room when seclusion room is not in use. As per AIA 1996/97 section 11. 2.B26 , facility is required to have a separate 'Quite room' of minimum 80 sq feet.
The Seclusion room is a separate requirement under 11. 2.C and may be of 60 square feet. During the survey when the seclusion room was measured, it was noted that the rooms were of approximately 72 sq feet. Thus, using the room for 'quiet room' not only does not comply with two separate room requirement, it also does not comply with the square footage requirement either.

15. During the tour of the facility, on some floors the staff indicated that the 'visitor's room' and 'Day room' are at times co-mingled for its use /purpose. As per AIA 1996/97 section 11.2.B16 requires two rooms for noisy and quite activities. The requirement clearly states that these spaces may be used for dinning purpose but does not indicated they may be used for 'visitor's room' purpose. The requirement of 'visitor's room' is separate and is under 11.2.B25.

Based on record review and staff interview, it was determined that the facility failed to perform and document an examination of orientation with supportive information in the psychiatric evaluation for 7 of 8 active sample patients (B, C, D, E, F, G, and H). These failures potentially result in a lack of identification of pathology, which may be pertinent to the current mental illness, and compromise future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

1. Patient B was admitted on 3/14/13. The psychiatric evaluation, done on 3/14/13 stated, "Orientation x 2-3". There was no supportive information documented.

2. Patient C was admitted on 5/8/13. The psychiatric evaluation, done on 5/8/13, stated, "Orientation x 1". There was no supportive information documented.

3. Patient D was admitted on 5/11/13. The psychiatric evaluation, done on 5/11/13, stated, "Orientation x 3". There was no supportive information documented.

4. Patient E was admitted on 5/6/13. The psychiatric evaluation, done on 5/6/13 stated, "Orientation x 3". There was no supportive information documented.

5. Patient F was admitted on 5/15/13. The psychiatric evaluation, done on 5/15/13, stated, "Orientation x 3". There was no supportive information documented.

6. Patient G was admitted on 5/7/13. The psychiatric evaluation, done on 5/7/13, stated, "Orientation x 3". There was no supportive information documented.

7. Patient H was admitted on 5/13/13. The psychiatric evaluation, done on 5/13/13, stated, "Orientation x 3". There was no supportive information documented.

B. Interview

During an interview on 5/21/13 at 2:00 p.m., the Medical Director agreed that the psychiatric evaluations did not document supportive information justifying the conclusions about orientation and stated, "I agree, it is something we need to do. This is easy fix."

Based on record review and staff interview, it was determined that the facility failed to provide psychiatric evaluations that included an assessment of patient assets in a descriptive fashion that could be used in choosing treatment for 5 of 8 sample patients (A, C, D, E, and G). The failure to identify patient assets in descriptive fashion impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings include:

A. Record Review

1. Patient A was admitted on 5/16/13. The patient assets included in psychiatric evaluation, done on 5/16/13 were "ambulatory, some improvement in from following previous admission [sic]". There was no assessment of patient assets documented in a descriptive fashion to be used in choosing treatment.

2. Patient C was admitted on 5/8/13. The patient assets included in psychiatric evaluation, done on 5/8/13 were "verbal, ambulatory". There was no assessment of patient assets documented in a descriptive fashion to be used in choosing treatment.

3. Patient D was admitted on 5/11/13. The patient assets included in psychiatric evaluation, done on 5/11/13 were "verbal, ambulatory". There was no assessment of patient assets documented in a descriptive fashion to be used in choosing treatment.

4. Patient E was admitted on 5/6/13. The patient assets included in psychiatric evaluation, done on 5/6/13 were "verbal". There was no assessment of patient assets documented in a descriptive fashion to be used in choosing treatment.

5. Patient G was admitted on 5/7/13. The patient assets included in psychiatric evaluation, done on 5/7/13 were "verbal, ambulatory". There was no assessment of patient assets documented in a descriptive fashion to be used in choosing treatment.

B. Interview

During an interview on 5/21/13 at 2:00 p.m., the Medical Director agreed that the psychiatric evaluations did not document patient assets in a descriptive fashion and stated, "I agree, it is something we need to do. No arguments there. This is an easy fix."

Based on observations of the patients, staff interviews, policies and procedures, and record reviews, the facility failed to include accurate nursing progress notes for one of eight sample patients (Record A). This failure results in relevant information not being communicated between treatment team members, depriving the patient of continuity of care. Additionally, the facility failed to include timely nursing progress notes in one of three death record patients (Record P). This failure of documentation results in the nursing staff being responsible for documentation that does not reach a minimal standard of care for the nursing profession.

Findings include:

1. Record A: Patient A was admitted on 5/16/13 with diagnoses of Dementia, Alzheimer's type with behavioral and psychotic changes and Schizoaffective Disorder.

On 5/20/13, at 10:00 a.m., the surveyor attempted to interview Patient A. At that time, Patient A did not speak, but did, however, communicate with the surveyor by writing notes. The Assistant Director of Nursing (ADON), who was present, stated that Patient A usually speaks and that he was surprised to see Patient A only wanted to communicate through writing.

On 5/20/13, at 10:30 a.m., Patient A was escorted to the conference room for a treatment planning meeting with Psychiatrist 2 and six other members of the treatment team. Patient A again did not speak and would only communicate by writing.

On 5/21/13, at 9:15 a.m., the ADON stated that he had tried to speak with Patient A the previous evening after the surveyors had left the facility, but that Patient A was still not speaking in the evening and would only write to communicate.

On 5/21/13, at 9:20 a.m., the surveyor again attempted to interview Patient A. Again, Patient A motioned for paper and pen and would only communicate through writing.

On 5/21/13, at 9:30 a.m., a review of the nursing progress notes for 5/20/13 reflected that there was no mention of Patient A writing to communicate throughout that day. The Nursing Note for 5/20/13 written at 2:00 p.m. stated: "Pt. is confused and disorganized. Has been irritable and distracted this morning. Maintained on close observation for falls and no falls noted." The Nursing Note for 5/20/13 written at 7:30 p.m. stated: "Patient seen in the dayroom - confuse and disorganize (sic), restless, guarded on approach. No aggressive behavior noted. Maintain on close observation for fall precaution."

On 5/21/13 at 9:50 a.m., Nurse 1 stated in an interview that Patient A's behavior of writing his/her communication as s/he had done the previous day was "very odd." Nurse 1 stated that he had not previously seen the patient write to communicate. The ADON also stated that the previous day was the first time that he had seen Patient A write to communicate.

On 5/21/13 at 9:55 a.m., Nurse 2 stated there was no mention of Patient A's written communication in the nursing notes "because [Patient A] had been writing [his/her] needs since she came into the hospital," and that therefore she did not think of it as "important information" to convey in Nursing Progress Notes. She stated, "It doesn't seem important to me."

On 5/21/13 at 10:00 a.m., the ADON stated that he thought Patient A's behavior of writing to communicate was significant enough information to warrant it being reflected in the nursing progress notes.

On 5/21/13 at 10:30 a.m., the DON stated that she "would expect to see something in the progress notes about [Patient A]'s behavior, even if it were not that elaborate. But I would expect to see something."

2. Record P: Patient P was admitted on 1/23/13 with a diagnosis of Cocaine and Alcohol Dependence and Schizoaffective Disorder.

Patient P had an acute vascular event on 1/27/13 and was reported to be dead when s/he arrived at the Emergency Room at the Medical Hospital. Three final nursing notes were written in the record. The notes were dated as 1/27/13 and timed as 10:55 p.m., 11:00 p.m., and 11:50 p.m. These notes were written and entered in the record after the on-call medical doctor wrote his note on 1/27/13 at 11:59 p.m.

In an interview on 5/21/13, the DON stated, "There is no policy for late entry progress notes. All notes are supposed to be written at the time of the event."

The DON and the ADON observed the nursing progress notes written on 1/27/12 at 10:55 p.m., 11:00 p.m., and 11:50 p.m. and acknowledged that the entries were written at later times than documented in the patient's record.

A review of the Department of Nursing Policy and Procedure Manual, revised 12/12 documents the Progress Notes Policy as follows:

"1) The RN in charge of the individual patient must document a minimum of one (1) note per 24 hours. 2) All Goal Plans must be numbers and addressed on the Progress notes as formulated by the RN in the Nursing Interventions."