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Based on observations, interviews, video footage, policy review, and submitted Plan of Correction (POC), it was determined the facility failed to have an effective Governing Body responsible for the conduct of the hospital. The facility's Governing Body failed to function effectively to manage the hospital's compliance with Conditions of Participation (COPs) for Patient Rights and Nursing Services, which resulted in failure to ensure corrective actions were implemented following a state agency complaint investigation with Immediate Jeopardy findings. The facility also failed to protect newborns from further abuse by allowing an alleged perpetrator to return to unauthorized areas of the hospital (Women's Health Unit).

Refer to findings in A0057.

The findings were:
The facility submitted an acceptable Plan of Correction (POC) on 08/09/13, alleging a correction date of 08/03/13. A review of the plan of correction revealed the facility implemented corrective actions that included the following: 1) On 07/26/13 the facility developed a step-by-step guide entitled, "Child/Infant Requiring Social Service Interventions" for personnel concerning the involvement of DCBS with the patients' care and the implementation of DCBS abuse prevention plans. Staff was educated to utilize the "Multidisciplinary Discharge Planning" nursing worksheet as a tool for a) guidance for visitation (if indicated); ...b) appropriate discharge; c) dissemination of information regarding visitation and discharge, as well as any other DCBS directions to nursing staff and the manner in which this information is to be communicated from shift to shift. In addition, the plan of correction stated staff was educated to ensure appropriate documentation of the visits and supervision of the visits in the infant's medical record and newborns required to have supervised visitation would be continuously monitored by nursing staff; ...4) All nurses and other personnel working in newborn nursery, labor and delivery, women's health, and pediatric units were retrained and educated on the 07/30/13 revisions to the policy entitled, "Suspected Child/Adult Neglect/Abuse," to immediately report to [the] hospital administrators and appropriate Kentucky authorities any potential patient abuse or neglect in accordance with Kentucky law and regulations as well as in accordance with the revised facility policy on "Suspected Child/Adult Neglect/Abuse," to include a phone number for reporting to external agencies after hours; ...6) Security cameras were installed in the newborn nursery and nursery visitation room on 08/02/13, in order to more closely observe activity in the nursery and surrounding areas.

Further review of the facility's plan of correction revealed the facility alleged a timely and thorough investigation was conducted in accordance with the facility's policy. The policy provides guidance for conducting the investigation and specifies the investigation should consist of the following: an interview with the person reporting the incident, a statement of the patient's physical condition, interviews with any witness to the incident, an interview with the patient if possible, a review of the patient's medical record if appropriate, an interview with other patients for which the employee has provided care if deemed appropriate, an interview with all staff members having contact with the patient as deemed appropriate, an interview of all circumstances surrounding the incident, results of the investigation will be recorded in the employee's confidential personnel file and forwarded to other hospital disciplines as deemed appropriate by the incident, and a report of the investigation will be handled as per state and regulatory guidelines.

Continued review of the plan of correction revealed the Women's Health staff was informed on 07/13/13, that the alleged perpetrator would not be allowed to return to work or permitted to enter the newborn nursery of the facility.

A full survey was initiated on 08/13/13, and identified that the facility failed to ensure the corrective actions in the POC were implemented. Immediate Jeopardy continued to exist in the areas of Patient Rights and Nursing Services.

Interviews with staff revealed the facility's education regarding "Child/Infant Requiring Social Service Interventions" policy was ineffective. Staff was not knowledgeable on who was responsible for completing the nursing worksheet that was required to be utilized to provide guidance for visitation, to ensure appropriate discharge, and to ensure information regarding visitation, discharge, and any other DCBS directions were communicated to staff. Review of medical records for Patients #11, #15, #18, and #26 revealed DCBS abuse prevention plans and/or protection orders were not implemented per policy.

Interviews with staff also revealed facility education/training on the revised "Suspected Child/Adult Neglect/Abuse" policy was not effective. Interviews revealed staff was unaware how to contact the appropriate state agencies to report alleged patient abuse or neglect after normal business hours.

Observation of security camera monitors for the newborn nursery and nursery visitation room revealed the cameras/monitors were not functioning. Interviews with staff revealed they were not aware the cameras/monitors were not functioning properly, even though staff was required to monitor patient supervision utilizing this system.

Multiple requests were made from 08/13/13 through 08/15/13, for evidence that a thorough, timely investigation was completed as required by the facility's policy and as stated in the facility's plan of correction. Interviews with the facility's Risk Manager and Chief Nursing Officer (CNO) revealed the facility's legal counsel had conducted an investigation of the allegation of abuse involving Patient #2; however, the Risk Manager and CNO stated the state agency was not permitted to obtain a copy of the investigation.

Interviews with facility staff and review of video footage revealed the alleged perpetrator returned to the Women's Health unit on 08/03/13, to obtain her personal belongings. Interview with RN #13, who allowed the alleged perpetrator to enter the Women's Health unit, revealed she had not received training from the facility and had no knowledge that the alleged perpetrator was not permitted on the Women's Health unit.

Based on interview and policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the hospital. The facility's Governing Body failed to function effectively to ensure the hospital's compliance with Conditions of Participation (COPs) for Patient Rights and Nursing Services, which resulted in failure to ensure corrective actions were implemented following a state agency complaint investigation with Immediate Jeopardy findings. The facility also failed to protect newborns from further abuse by allowing an alleged perpetrator to return to an unauthorized patient care area of the hospital (Women's Health Unit).

The findings include:

A policy addressing Governing Body, along with a list of the Governing Body members entitled Board of Directors, was submitted by the facility as "Bylaws of Baptist Healthcare System, Inc." Review of Bylaws of Baptist Healthcare System (BHS), Section 1.03 "Responsibilities of the Board of Directors," revealed the Board of Directors shall be responsible for the development of policy, fulfillment of the mission, and overall management of operations. The review further revealed the Board of Directors/Governing Body members shall be responsible for: ...2) overseeing ongoing commitments to the Baptist heritage of Christ-centered approach to healthcare delivery; ...11) providing oversight management and final approval to those matters not delegated to a committee or management or required by law.

Interview on 08/14/13, at 3:15 PM, with the facility President, revealed there were two Governing Bodies; one was local and located at the facility and the other one was corporate. The President stated the local Governing Body was informed of the Immediate Jeopardy findings on 07/25/13. The interview revealed the President e-mailed the Corporate Chief Executive Officer (CEO) a summary of the Immediate Jeopardy findings and the Corporate CEO then notified the Corporate Governing Body of the findings. According to the President, neither Governing Body (local nor corporate) was involved in the development of the POC nor the corrective actions taken by the facility related to the findings on 07/25/13. The President explained the Governing Body was more involved in the operational processes, not the clinical processes of the facility. The President stated the Governing Body expected the President to address any issues/problems accordingly and ensure compliance.

The POC the facility submitted with an alleged correction date of 08/03/13 revealed the governing body failed to implement corrective actions to protect vulnerable newborn infants from abuse and failed to ensure staff was knowledgeable/trained to ensure that vulnerable newborn infants were protected from further potential abuse. The plan of correction stated the facility implemented a new policy regarding the safety of newborns under DCBS care, which included the implementation of a worksheet to communicate and ensure DCBS abuse prevention plans were followed in the newborn nursery. Interviews with staff and review of patient records revealed the education was ineffective and DCBS abuse prevention plans were not being followed. In addition, the facility's plan of correction stated staff was in-serviced on the facility's revised abuse policy to immediately report abuse allegations to the appropriate state agencies. However, interviews with staff revealed they were unaware of how to contact state agencies related to reporting abuse after normal business hours.

Further review of the facility's plan of correction revealed the facility installed security cameras in the newborn nursery and nursery visitation room in order to more closely monitor the safety of newborns. Observations on 08/13/13, revealed the cameras/monitors were nonfunctional and staff was unaware they were not functioning properly. This was verified during an interview with the Women's Health Director on 08/13/13 at 11:40 AM.

The plan of correction further stated the Women's Health staff was informed on 07/13/13, that the alleged perpetrator would not be allowed to return to work or permitted to enter the newborn nursery. However, interviews with facility staff and review of video footage revealed the alleged perpetrator returned to the Women's Health unit on 08/03/13, to obtain her personal belongings. Interview with RN #13, who allowed the alleged perpetrator to enter the unit, revealed she had not received training from the facility and had no knowledge that the alleged perpetrator was not permitted to enter patient care areas (Women's Health unit) after being terminated from the facility.

Based on interview, record review, and review of the facility's policies, Plan of Correction, and documents, it was determined the facility failed to have mechanisms/methods in place to protect four unsampled newborn patients from potential abuse when the alleged perpetrator (accused of abusing a newborn patient on 07/10/13) was allowed to return to the facility on Saturday, 08/03/13, and to enter an unauthorized patient care area (Women's Health unit). The facility failed to ensure all patients received care in a safe setting for four of thirty-one sampled patients (Patients #11, #15, #18, and #26). A plan of correction (POC) was received/accepted on 08/09/13, with a correction date of 08/03/13. A full survey was initiated on 08/13/13, which found the Immediate Jeopardy continued to exist, and further examples were identified. The facility failed to ensure the plan of correction was implemented and that Department for Community Based Services (DCBS) abuse prevention plans were followed. The facility failed to ensure Patients #11, #15, and #18 were supervised at all times when the patients' parents were present as required by DCBS. The facility failed to ensure a court order from the Department of Juvenile Justice (DJJ) was implemented for Patient #26 and failed to provide evidence of the facility's thorough investigation of the abuse allegation until 08/15/13.

In addition, the facility failed to ensure security cameras that were installed on 08/02/13, as part of the facility's POC, were functioning to ensure supervision/protection of the newborns while in the nursery.

Refer to findings in A0144 and A0145.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure all patients received care in a safe setting for four of thirty-one sampled patients (Patients #11, #15, #18, and #26). Immediate Jeopardy was identified on 07/25/13, during a complaint investigation (KY20453). A plan of correction (POC) was received/accepted on 08/09/13, with a correction date of 08/03/13. A full survey was initiated on 08/13/13, which found the Immediate Jeopardy continued to exist, and further examples were identified. The facility failed to ensure the plan of correction was implemented and that Department for Community Based Services (DCBS) abuse prevention plans were followed. The facility failed to ensure Patients #11, #15, and #18 were supervised at all times when the patients' parents were present as required by DCBS. The facility failed to ensure a court order from the Department of Juvenile Justice (DJJ) was implemented for Patient #26.

In addition, the facility failed to ensure security cameras that were installed on 08/02/13 as part of the facility's POC were functioning.

The findings include:

A review of the policy titled "Child/Infant Requiring Social Service Interventions," dated 07/26/13, revealed that only when social issues are identified to include a history of drug abuse will staff order a consultation for Social Services and a drug screen for the infant. Findings of Social Services will be documented in their notes and communicated to staff caring for the infant. If DCBS is notified, documentation will be in the Social Services notes and on the discharge planning sheet on the infant's record.

The POC submitted by the facility which alleged compliance 08/03/13, was not implemented and staff education was ineffective. On 07/26/13, the facility developed a step-by-step guide entitled "Child/Infant Requiring Social Service Interventions" for personnel concerning the involvement of DCBS with the patients' care and the implementation of DCBS abuse prevention plans. Staff was educated to utilize the "Multidisciplinary Discharge Planning" nursing worksheet as a tool for: a) guidance for visitation (if indicated); b) appropriate discharge; and c) dissemination of information regarding visitation and discharge as well as any other DCBS directions to nursing staff and the manner in which this information is to be communicated from shift to shift. In addition, the POC stated staff was educated to ensure appropriate documentation of the visits and supervision of the visits in the infants' medical record and newborns required to have supervised visitation would be continuously monitored by nursing staff.

On 08/13/13 at 11:10 AM, interviews with staff revealed the facility's education regarding the "Child/Infant Requiring Social Service Interventions" policy was ineffective, as evidenced by: Staff was not knowledgeable of who was responsible for completing the nursing worksheet that was required to be utilized to provide guidance for visitation, to ensure appropriate discharge, and to ensure information regarding supervised visitation of the newborns, discharge, and any other DCBS directions was communicated to staff. Review of medical records for Patients #11, #15, #18, and #26 revealed DCBS abuse prevention plans and/or protection orders were not implemented per policy.

Interview with the Chief Nursing Officer (CNO) on 08/13/13, at 2:05 PM, revealed the facility screened all newborns and their mothers for drugs and if the screen was positive for the mother and/or baby, or if the mother appeared impaired, the facility notified DCBS of the findings of the drug screening and facility staff would supervise all visits with the newborn and mother until DCBS developed an abuse prevention/parenting plan. However, the information provided during interview conflicted with the "Child/Infant Requiring Social Service Interventions" policy dated 07/26/13.

Interview on 08/13/13, at 11:15 AM, with the Executive Director of Nursing (EDON) revealed that the facility's corrective action plan submitted on 08/09/13 stated the facility had developed a Multidisciplinary Discharge Planning policy. However, the interview revealed a newly developed Multidisciplinary Discharge Planning form was not a policy but a process. The newly developed Multidisciplinary Discharge Planning form was to be utilized by nursing staff along with the patient's care plan to ensure DCBS abuse prevention plans were implemented and followed for the safety of the patients. The EDON reported nursing staff received in-service education on the utilization of the Multidisciplinary Discharge Planning form; however, the facility failed to develop a written process that addressed who was responsible for completing specific sections of the form. A written process was developed and given to the survey team on 08/13/13.

1. The facility admitted Patient #11 on 08/11/13, with a diagnosis of Term Birth Living Child and a positive urine drug screen for marijuana. The facility contacted DCBS due to the patient's positive drug screen and DCBS developed interventions on the abuse prevention/parenting plan, including discharge instructions for supervision, to ensure the patient's safety after discharge. However, facility staff failed to document/include the details of the prevention/parenting plan developed by DCBS on the facility's discharge plan.

2. The facility admitted Patient #15 on 08/06/13, with a diagnosis of Term Birth Living Child and identified the patient to be at risk for Neonatal Abstinence Syndrome (group of problems that occur in newborns who were exposed to addictive or prescription drugs while in the mother's womb). On 08/06/13, at 11:30 PM, RN #2 informed the facility's social worker that the patient's drug screen was positive for Buprenorphine (an opioid) and the patient's meconium drug screen was pending. On 08/07/13, at 10:00 AM, the facility's social worker contacted DCBS to report the positive drug screen; DCBS accepted the case and instructed the facility social worker to continue supervised visits between mother and patient.

Documentation dated 08/07/13, at 3:00 AM, in the nursing notes revealed Patient #15 was bottle fed by the patient's mother. However, the location of the feeding was not documented. The nursing staff failed to document if the staff supervised the visit with the newborn as per the instructions of DCBS.

3. The facility admitted Patient #18 on 08/03/13, with a diagnosis of Term Birth Living Child and noted the patient was at risk for withdrawal from drugs. A review of nursing notes dated 08/05/13, at 9:00 AM, revealed Patient #18's father was to transport the baby at discharge. However, a review of the facility's social worker notes dated 08/05/13, at 2:00 PM, revealed DCBS developed an abuse prevention/parenting plan. According to the plan, Patient #18's father was not permitted to hold the patient and staff was to supervise visits with the patient by the parents. A review of nursing notes dated 08/05/13, at 5:20 PM, revealed DCBS assessed Patient #18 and instructed nursing staff to ensure the baby remained in the nursery and, when the parents visited the patient, the visits were to be supervised. Continued review of documentation revealed although the patient's parents visited the newborn numerous times at the facility, the facility failed to ensure staff had documentation to support visits were supervised as per DCBS abuse prevention plans for the protection of the newborn. The facility staff lacked clear delineation as to who was responsible for communicating the DCBS abuse prevention plans for newborns.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed the facility's social worker was responsible for ensuring appropriate discharge planning, including the DCBS discharge plan. RN #14 further stated that nursing staff was not always aware when DCBS came to the facility and that Patient #18's care plan had not been updated and revised to show the DCBS abuse prevention/parenting plan to ensure the infant's safety.

Interview with Social Worker #1 on 08/13/13, at 11:15 AM, revealed the facility social worker would be notified when babies tested positive for drugs and/or showed signs and symptoms of drug withdrawal. According to Social Worker #1, a referral would be made to DCBS by the facility social worker. Social Worker #1 stated a new discharge plan would be revised to show discharge instructions for infants involved with DCBS. However, Social Worker #1 stated nursing staff was responsible for ensuring appropriate discharge for the mom and baby.

4. The facility admitted Patient #26 on 08/16/13, with diagnoses of Drug and Alcohol Abuse, Attention Deficit/Hyperactivity Disorder, Depression, and Suicidal Attempts, and for safety and stabilization. A review of documentation on a court order dated 08/21/12 revealed Patient #26 had been removed from his/her home and committed to DJJ. According to the court order, Patient #26 was to have supervised contact with his/her mother. In addition, documentation on the court order revealed Patient #26 was detained for treatment at the facility and was to be discharged back to DJJ custody. According to a therapy note in the behavioral health section of the medical record, the "primary treatment team" was to involve the "necessary parties" regarding Patient #26's safety planning and disposition. However, the Behavioral Health Treatment Plan initiated by the facility's social worker on 08/17/13, failed to include DJJ's involvement in the patient's care.

Interview with RN #11 on 08/19/13, at 1:20 PM, revealed that she was responsible for the care and safety of Patient #26. RN #11 stated the DJJ worker came to the facility on 08/19/13, at 8:00 AM, and left the court order showing Patient #26 had been placed in the custody of DJJ. However, RN #11 stated she did not know whose responsibility it was to document the information.

Interview with the Director of Behavioral Health on 08/21/13, at 10:45 AM, revealed the facility's social workers routinely conducted discharge planning. The Director stated the on-call weekend social worker had initiated a Behavioral Health Treatment Plan for Patient #26. The interview revealed no explanation why the record failed to include DJJ custody of Patient #26. The Director was unaware nursing staff did not know who was responsible to add custody information to the medical record.

5. The facility's Immediate Jeopardy corrective actions stated on 08/02/13, the facility installed security cameras in patient care areas to closely observe activity for patient safety.

The facility alleged staff in-service training on implementation of the new/revised policy/process related to abuse and protection and the installation of the security monitoring system for the safety of the patients had been completed as of 08/03/13.

A tour of the nursery and interviews with RN#13, RN #14, and the Director of Women's Health were conducted on 08/13/13, at 11:40 AM. Observation revealed a security camera had been installed in the nursery visitation room. RN #14 stated staff supervised the visitation room by means of the camera and a monitor that was located at the "nursery" nursing station. However, observation of the monitor at the nursing station revealed there was an "error" message on the screen and the visitation room could not be viewed by use of the monitor. Interviews with RN #14, RN #13, and the Director of Women's Health during the tour revealed the video surveillance had been functional and they were unaware the video surveillance was not functional at the time of the observation on 08/13/13. The facility failed to ensure that the POC was followed by not ensuring that the video surveillance monitor was functional to ensure that newborns were protected/monitored and supervised during the visits in the nursery.

Based on interview, record review, and review of the facility's policies, personnel files, and documents, it was determined the facility failed to have mechanisms/methods in place to protect four unsampled newborn patients from potential abuse when the alleged perpetrator (accused of abusing a newborn patient on 07/10/13) was allowed to return to the facility on 08/03/13, and to enter an unauthorized patient care area (Women's Health Unit); and failed to provide evidence of the facility's thorough investigation of the abuse allegation until 08/15/13.

The findings include:

A review of the facility's policy entitled "Your Rights and Responsibilities as a Hospital Patient," dated 03/28/11, revealed, "You have the right to receive care in a safe setting, and to be free from abuse and harassment."

1. A review of the alleged perpetrator's personnel file revealed the facility suspended the alleged perpetrator on 07/15/13, four days after an observation of the alleged perpetrator allegedly abusing a newborn baby, and initiated an investigation of the allegation on 07/16/13 (six days after the abuse occurred). The alleged perpetrator was terminated on 07/30/13 (twenty days after the abuse occurred).

The facility's Immediate Jeopardy corrective actions received on 08/09/13 revealed staff was made aware that the alleged perpetrator would not be allowed to come into the newborn nursery of the facility and alleged as of 08/03/13 facility staff had completed an in-service training related to patient safety.

Interviews on 08/13/13, at 11:40 AM, with the facility President and Chief Nursing Officer (CNO) revealed the alleged perpetrator was suspended from employment pending the completion of the facility's investigation and was terminated on 07/30/13, for failing to follow the Code of Conduct related to the use of abusive language during his/her (alleged perpetrator) patient care activities. This interview verified that the staff was not aware and/or trained that the alleged perpetrator was not allowed to come to the Women's Health unit prior to the submission of the POC on 08/08/13.

Interview on 08/13/13, at 2:05 PM, with the facility's CNO revealed the alleged perpetrator was instructed not to return to unauthorized patient care areas without security. The interview revealed staff assigned to the Women's Health unit was instructed by the Director of Women's Health that the alleged perpetrator was not allowed to be on the unit without security and a "note" that instructed staff to not allow the alleged perpetrator in the nursery was placed on the unit schedule for staff to view.

A review of a letter dated 08/02/13, addressed to the alleged perpetrator, revealed the employee was terminated via a telephone conversation on 07/30/13. The letter stated, "During our investigation it came to our attention from several staff that you have been using angry and profane language in your patient care activities which is in direct violation of our code of conduct, which you sign on an annual basis." However, there was no documentation in the letter that the alleged perpetrator had been instructed not to return to the facility.

Interview with RN #13 on 08/13/13, at 11:10 AM, revealed that she had been trained on the revised abuse and reporting policy "in the last week or so." However, RN #13 acknowledged she had unlocked the Women's Health unit door on Saturday, 08/03/13, and allowed the alleged perpetrator into unauthorized patient care areas of the hospital. The interview further revealed that RN #13 did not inform Security at the time the alleged perpetrator was in the facility, and failed to inform the Director of Women's Health that the alleged perpetrator had returned to the facility on 08/03/13, until Monday, 08/12/13, nine days after the alleged perpetrator presented to the facility.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed she had received "recent" trainings related to the abuse and reporting policy. However, RN #14 stated the subject of the alleged perpetrator and what to do if the alleged perpetrator presented to the facility had never been brought up during the trainings.

Interview on 08/14/13, at 11:00 AM, with the Director of Security revealed prior to 08/13/13 the facility had not informed and/or provided him of any concerns with the alleged perpetrator, and he had not been instructed to not allow the alleged perpetrator to enter the facility.

However, on 08/14/13, at 1:10 PM, a review of video surveillance of the Women's Health unit for the afternoon of Saturday, 08/03/13, revealed RN #4 and RN #13 working with four newborns in the nursery. Further review of the video surveillance for 08/03/13, revealed at 2:27 PM, RN #13 met the alleged perpetrator, who had been terminated from the facility, at the door to the nursery and allowed the alleged perpetrator, without security supervision, into the unauthorized patient care areas (Women's Health Unit) of the facility. Continued review of the video revealed at 2:32 PM, the alleged perpetrator left the unauthorized patient care area carrying a bag in her hand.

Interview on 08/14/13, at 1:10 PM, with the Director of Women's Health revealed she was unaware that the alleged perpetrator had been back on the Women's Health unit.

2. An acceptable Plan of Correction (POC) was received on 08/09/13, alleging a correction date of 08/03/13. A review of the POC revealed the facility implemented corrective actions including: The facility's policy, entitled Suspected Child/Adult Neglect/Abuse, was revised on 07/30/13, and included "When an incident or suspected incident of abuse or neglect, or injury of unknown origin is reported, the Administrator on call will be notified and the appropriate state agencies." The policy also revealed, "The Risk Management department and BHS Legal Counsel will lead the investigation. All nurses and other personnel working in newborn nursery, labor and delivery, women's health, and pediatric units were retrained and educated on 07/30/13, related to revisions to the policy entitled, 'Suspected Child/Adult Neglect/Abuse.'"

Interview on 08/14/13, at 2:00 PM, with the Director of Risk Management confirmed that in accordance with the facility's abuse policy, injuries of unknown origin would be investigated by the Risk Management Department and the facility's "Legal" services. After it was determined via x-ray (on 07/15/13) and interview with the Radiologist (on 07/22/13) that the injury was "consistent with an abuse-type injury," interview with the Director of Risk Management revealed the facility's Risk Management Department failed to conduct an investigation as per the facility's policy of an abuse allegation involving the injury of a newborn patient's fractured arm.

Interviews on 08/13/13, at 4:10 PM, with the Chief Nursing Officer (CNO) and Director of Risk Management revealed that the facility's Legal Counsel had conducted the investigation of the allegation that the alleged perpetrator was verbally and physically abusive to a newborn patient. However, the facility failed to provide a true copy of the investigation to the state agency for review due to legal issues.

After multiple requests by the state agency surveyors (from 8/13/13 to 8/14/13) for the facility to produce evidence of a timely, thorough investigation of the alleged abuse of the newborn patient, as per the facility's POC, the facility's President agreed on 08/14/13, at 5:30 PM, that the facility would compose a summary of Legal Counsel's investigation to present to surveyors on the morning of 08/15/13.

Based on interview, review of medical records, Facility Plan of Correction, State Agency Abuse Prevention Plans, and the facility's policy, it was determined the facility failed to ensure that each patient's rights were protected and promoted through nursing supervision by failing to ensure the facility plan of correction was implemented and that Department for Community Based Services (DCBS) plans were followed to ensure patients were supervised at all times when the patients' parents were present as required by DCBS for two (Patients #15 and #18) of thirty-one medical records reviewed. The facility also failed to ensure a court order from the Department of Juvenile Justice (DJJ) was implemented for Patient #26.

Refer to findings in A0395.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure nursing staff developed, and kept current, a nursing care plan related to safety and supervision for four of thirty-one sampled patients (Patients #11, #15, #18, and #26).

Refer to findings in A0396.

Based on interviews and reviews of medical records, Facility Plan of Correction, State Agency Abuse Prevention Plans, and the facility's policy it was determined the facility failed to ensure that each patient's rights were protected and promoted through nursing supervision by failing to ensure the facility's plan of correction was implemented and that Department for Community Based Services (DCBS) plans were followed to ensure patients were supervised at all times when the patients' parents were present as required by DCBS for two (Patients #15 and #18) of thirty-one medical records reviewed. The facility also failed to ensure a court order from the Department of Juvenile Justice (DJJ) was implemented for Patient #26.

The findings include:

An acceptable Plan of Correction (POC) was received on 08/09/13, alleging a correction date of 08/03/13. A review of the plan of correction revealed the facility implemented corrective actions including: On 07/26/13, developed a step-by-step guide entitled "Child/Infant Requiring Social Service Interventions" for personnel in regard to the involvement of DCBS with the patients' care and the implementation of DCBS abuse prevention plans. Staff was educated to utilize the Multiple Disciplinary Discharge Planning" nursing worksheet as a tool for a) guidance for visitation (if indicated); b) appropriate discharge; and c) dissemination of information regarding visitation and discharge, as well as any other DCBS directions to nursing staff and the manner in which this information is to be communicated from shift to shift. In addition, the plan of correction stated staff was educated to ensure appropriate documentation of the visits and supervision of the visits in the infant's medical record and newborns required to have supervised visitation would be continuously monitored by nursing staff.

Interviews with staff revealed the facility's education regarding "Child/Infant Requiring Social Service Interventions" policy was ineffective. Staff was not knowledgeable of who was responsible for completing the nursing worksheet that was required to be utilized to provide guidance for visitation, to ensure appropriate discharge, and to ensure information regarding visitation, discharge, and any other DCBS directions was communicated to staff. Review of medical records for Patients #15, #18, and #26 revealed DCBS abuse prevention plans and/or protection orders were not implemented per policy.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed that she had received training on the facility's newly developed drug screen policy for infants and on the facility's newly developed discharge planning form. The interview revealed the facility's social worker would request a copy from the patient's parent of the DCBS abuse prevention/parenting plan for patients with DCBS oversight. RN #14 stated there was a lack of communication between the facility staff and representatives from DCBS and, as a result, the facility did not always have the information related to the abuse prevention/parenting plan developed by DCBS.

Interview with the Chief Nursing Officer (CNO) on 08/13/13, at 2:05 PM, revealed the facility screened all newborns and their mothers for drugs and if the screen was positive for the mother and/or baby, or if the mother appeared impaired, the facility notified DCBS of the findings of the drug screening and facility staff would supervise all visits with the newborn and mother until DCBS developed an abuse prevention/parenting plan. However, the information provided during interview conflicted with the "Child/Infant Requiring Social Service Interventions" policy, dated 07/26/13. The facility policy did not detail that all newborns and mothers would be screened for drugs.

Interview on 08/13/13, at 11:15 AM, with the Executive Director of Nursing (EDON) revealed that even though the facility's corrective action plan submitted on 08/09/13 stated the facility had developed a Multidisciplinary Discharge Planning policy, the policy had not been developed/completed. However, the interview revealed the newly developed Multidisciplinary Discharge Planning form was not a policy but a process. The newly developed Multidisciplinary Discharge Planning form was to be utilized by nursing staff along with the patient's care plan to ensure the DCBS abuse prevention plan was implemented and followed for the safety of the patients. The EDON reported nursing staff received in-service education on the utilization of the Multidisciplinary Discharge Planning form. However, the facility failed to develop a procedure that addressed who was responsible for completing the specific sections of the form.

1. Medical record review revealed the facility admitted Patient #15 on 08/06/13, with a diagnosis of Term Birth Living Child and risk for neonatal abstinence syndrome (group of problems that occur in newborns who were exposed to addictive or prescription drugs while in the mother's womb). Review of the nursing notes dated 08/06/13, at 11:30 PM, revealed RN #2 contacted the facility social worker regarding the patient's positive buprenorphine drug screen, and that the patient's meconium drug screen was pending. On 08/07/13, at 10:00 AM, the facility social worker consulted DCBS to report the positive buprenorphine drug screen. DCBS accepted the case and instructed the facility social worker to continue to supervise visits between mother and patient. A nursing note dated 08/07/13, at 3:00 AM, revealed Patient #15 was bottle fed by mom but the location of the feeding was not documented and the charting graph was left blank. The facility failed to ensure the mom was supervised during visits with the newborn as per DCBS instructions. In addition, the nursing note dated 08/07/13, at 8:30 AM, revealed the patient was bottle fed by mom, but contained no documentation of location or nursing supervision.

2. The facility admitted Patient #18 on 08/03/13, with a diagnosis of Term Birth Living Child and risk for withdrawal from drugs. Review of the facility social worker notes dated 08/05/13, at 2:00 PM, revealed DCBS developed an abuse prevention/parenting plan. A review of the abuse prevention/parenting plan for Patient #18 revealed DCBS required staff to supervise visits with the mother and father and not allow the patient's father to hold the infant patient. However, a nursing note dated 08/05/13, at 9:00 AM, revealed Patient #18's father was to transport the baby at discharge. The nursing note dated 08/05/13, at 5:20 PM, revealed DCBS saw Patient #18 and instructed nursing staff to ensure the baby remained in the nursery and that visits with the baby were supervised by staff in the nursery. A review of Patient #18's record revealed no evidence staff supervised parental visits with Patient #18 on 08/05/13, at 6:00 PM and 9:00 PM. In addition, there was no documentation of supervision when the parent visited on 08/06/13, at 12:00 AM and 3:10 AM.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed DCBS did not provide the facility with a copy of their recommendations. However, according to RN #14, the facility social worker obtained copies of the abuse prevention/parenting plans from the mother of those infants involved with DCBS and placed copies in the medical records. RN #14 stated the social worker was responsible for ensuring appropriate discharge planning. RN #14 further stated that nursing staff was not always aware when DCBS came to the facility and/or when abuse prevention plans had been developed by DCBS. The interview gave no explanation why Patients #15 and #18's care plans had not been updated and revised to show a DCBS abuse prevention/parenting plan to ensure the infants' safety/supervision.

Social Worker #1 stated in interview on 08/13/13, at 11:15 AM, that staff notified the facility social worker when babies tested positive for drugs and/or showed signs and symptoms of drug withdrawal. According to Social Worker #1, a referral was made to DCBS by the facility social worker. Social Worker #1 stated a new discharge plan was revised to show discharge instructions for infants involved with DCBS. Social Worker #1 stated nursing staff was responsible for ensuring appropriate discharge per DCBS requirements for the mom and baby. Social Worker #1 stated she was unaware if a policy had been developed regarding the implemented parenting/abuse prevention plan and was not aware of the nursing process for supervised visitation. The facility failed to ensure that the POC submitted to the state survey agency for Immediate Jeopardy findings was followed/implemented related to abuse prevention as evidenced by staff knowledge of when and if policies and procedures were implemented to ensure proper supervision of the newborns as per DCBS instructions related to abuse prevention.

3. The facility admitted Patient #26 on 08/16/13, with diagnoses of drug and alcohol abuse, attention deficit/hyperactivity disorder, depression, and suicidal attempts. Further review revealed the patient was admitted to the adolescent psychiatric unit for safety and stabilization. According to the behavioral health daily therapy note dated 08/18/13, the primary treatment team was to involve necessary parties regarding disposition and safety planning. Review of the court order entered 08/12/08, revealed Patient #26 was to have no unsupervised contact with the mother. Review of the court order entered 08/21/12, revealed Patient #26 had been removed from the home and committed to DJJ. Patient #26 was detained pending placement and was to be released to DJJ. Review of the nursing care plan revealed no evidence nursing staff was aware Patient #26 was under DJJ custody or was to be released to DJJ upon discharge. In addition, the Behavioral Health Treatment Plan initiated by the facility social worker on 08/17/13 failed to include DJJ's involvement.

Interview with RN #11 on 08/19/13, at 1:20 PM, revealed RN #11 was responsible for the care and safety of Patient #26. RN #11 was aware Patient #26 had a court date scheduled for 08/20/13. RN #11 stated she was unsure if the mother would be transporting Patient #26 to court or if the mother would be going to court for the patient. RN #11 stated the DJJ worker came to the facility at 8:00 AM on 08/19/13, and left the court order entered on 08/21/12, which showed Patient #26 had been placed in DJJ custody. When asked if this information had been added to Patient #26's nursing care plan, the RN stated, "I didn't know I was supposed to do that."

Interview with the Director of Behavioral Health on 08/21/13, at 10:45 AM, revealed the facility's social services staff routinely conducted discharge planning. The Director stated the on-call weekend social worker had initiated a Behavioral Health Treatment Plan for Patient #26. The interview gave no explanation why the plan failed to include DJJ custody of Patient #26 and the Director was unaware nursing staff did not know they were responsible for adding custody information to the patient's nursing care plan. The nursing staff failed to supervise and evaluate the care of Patient #26 when new information from DJJ was brought to their attention, regarding the change in the patient's custody status.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure nursing staff developed, and kept current, a nursing care plan related to Safety and Supervision for four of thirty-one sampled patients (Patients #11, #15, #18, and #26).

The findings include:

Review of facility policy titled "Patient Assessment/Reassessment," revised 07/13/13, revealed "an individualized plan of care would be developed, documented and provided in coordination with the patient family or designated individual." The policy also revealed "integration and interventions of other disciplines from the identified needs during the initial assessments would be reviewed or revised as care dictated." According to the policy, "the plan was to be updated as appropriate following changes in the patient's condition."

The facility conducted routine drug screenings of Patients #11, #15, and #18 during the course of their hospitalization and identified the patients as being positive for and/or at risk for withdrawal from controlled substances including narcotics and opioids. The facility notified the Department for Community Based Services (DCBS) of the results of the patients' drug screens and DCBS assessed and provided direction related to the required supervision during the hospitalization and discharge planning.

1. The facility admitted Patient #11 on 08/11/13, with a diagnosis of Term Birth Living Child and identified the patient had a positive urine drug screen for marijuana. DCBS developed and provided the facility with an abuse prevention/parenting plan related to the safety/supervision; however, the facility failed to ensure the interventions recommended on the abuse prevention/parenting plan were incorporated in the nursing care plan.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed that Patient #11 had DCBS involvement but the only way the facility obtained the abuse prevention/parenting plan was for the facility social worker to request a copy from Patient #11's mother. RN #14 revealed if the mother had not allowed the facility to copy the DCBS plan the facility would not have been aware of the required supervision for the safety of Patient #11. The interview revealed there was a lack of communication between facility staff and DCBS, regarding the abuse prevention plan, in order to appropriately care plan Patient #11 related to supervision during visits.

2. The facility admitted Patient #15 on 08/06/13, with a diagnosis of Term Birth Living Child and identified the patient to be at risk for Neonatal Abstinence Syndrome. On 08/06/13, at 11:30 PM, RN #2 informed the facility's social worker the patient's drug screen for Buprenorphine (an opioid) was positive. On 08/07/13, at 10:00 AM, the social worker contacted DCBS to report the positive drug screen and DCBS accepted the case for investigation, according to the social worker's progress note. A review of documentation in the medical record revealed DCBS informed the facility social worker to continue to supervise visits between mother and patient. However, a review of documentation revealed there was no evidence the recommendations of supervision had been incorporated in the care plan.

3. The facility admitted Patient #18 on 08/03/13, with a diagnosis of Term Birth Living Child and identified the patient to be at risk for withdrawal from drugs. A review of nursing notes dated 08/05/13, at 9:00 AM, revealed that the father of the baby was to transport the baby at discharge. However, a review of the facility's social worker notes dated 08/05/13, at 2:00 PM, revealed DCBS developed an abuse protection/parenting plan that stated the patient's father was not to hold the baby and the baby could not be unsupervised with the mother or father. However, the nurse's notes on 08/05/13, at 5:20 PM, revealed DCBS saw Patient #18 and instructed staff to ensure the baby remained in the nursery and that the parents were to only visit the baby in the nursery. There was no evidence found that nursing staff had updated/revised Patient #18's care plan to show DCBS updates.

Interview with RN #14 on 8/13/13, at 11:25 AM, revealed the facility social worker was responsible for obtaining copies of the abuse prevention/parenting plans from the mothers of those infants involved with DCBS. According to RN #14, the social worker was responsible for ensuring appropriate discharge planning. RN #14 further stated that Nursing was not always aware when DCBS came to the facility. RN #14 gave no explanation for why Patient #18's care plan had not been updated and revised to show DCBS recommendations to ensure the infant's safety.

Interviews with Nursing and Social Services were conflicting. Interview with Social Worker #1 on 08/13/13, at 11:15 AM, revealed the facility social worker was called when babies showed positive for drugs and/or showed signs and symptoms of drug withdrawal. According to Social Worker #1, a referral was made to DCBS by the facility social worker. Social Worker #1 stated a new discharge plan had been revised to show discharge instructions for infants involved with DCBS. The Social Worker stated nursing staff was responsible for ensuring appropriate discharge for the mom and baby.

4. The facility admitted Patient #26 on 08/16/13, with diagnoses of Drug and Alcohol Abuse, Attention Deficit/Hyperactivity Disorder, Depression, and Suicidal Attempts. Documentation revealed Patient #26 had been removed from the home and was committed to the Department of Juvenile Justice (DJJ). Further review revealed the patient was admitted to the adolescent psychiatric unit for safety and stabilization after being medically cleared. Review of the social history revealed the patient was currently on home incarceration and in the custody of the mother but custody had been removed several times and the patient was placed under the care of the state. Review of the court order entered 08/12/08, revealed Patient #26 was to have no unsupervised contact with the mother.

Review of the court order dated 10/02/10, revealed the patient had been charged with Fourth Degree assault of the mother. Review of the court order entered 08/21/12, revealed Patient #26 had been removed from the home and committed to DJJ. Patient #26 was detained pending placement and to be released to DJJ. A review of the behavioral health therapy notes dated 08/18/13, revealed DJJ was involved in the patient's care and that the patient had a probation and parole officer but continued to live with the mother.

According to the behavioral health daily therapy note, the primary treatment team was to involve necessary parties regarding disposition and safety planning. Review of the nursing care plan dated 08/17/13, revealed no evidence that nursing staff was aware Patient #26 was under DJJ custody. Review of the behavioral health treatment plan dated 08/17/13, revealed staff had identified Patient #26 was on house arrest for assault with a court date of 08/20/13. However, there was no documentation in the behavioral health treatment plan that Patient #26 was court ordered to be released to DJJ upon discharge.

Interview with RN #11 on 08/19/13, at 1:20 PM, revealed RN #11 was responsible for the care and safety of Patient #26. RN #11 was aware that Patient #26 had a court date scheduled for 08/20/13. RN #11 stated she was unsure if the mother would be transporting Patient #26 to court or if the mother would be going to court for the patient. RN #11 stated the DJJ worker came to the facility that morning (08/19/13) at 8:00 AM, and left the court order paperwork showing the patient had been placed in DJJ custody. However, there was no documentation that the information related to the court order had been added to Patient #26's care plan and the RN stated, "I didn't know I was supposed to do that." In addition, the Behavioral Health Treatment Plan initiated by Social Services on 08/17/13 failed to include DJJ's involvement.

Interview with the Director of Behavioral Health on 08/21/13, at 10:45 AM, revealed Social Services normally conducted discharge planning. The Director stated the on-call weekend social worker had initiated a Behavioral Health Treatment Plan related to Patient #26's care and treatment. The Director gave no explanation for the Behavioral Health Treatment Plan failing to include DJJ custody of Patient #26. In addition, the Director was unaware that nursing staff did not know they were supposed to add custody information to their nursing care plan.

Even though DCBS and DJJ provided the facility with information related to the level of supervision and discharge planning to ensure the safety for Patients #11, #15, #18, and #26, there was no evidence the facility had developed a plan of care that was individualized or that was revised and updated to reflect the patients' needs for safety and supervision as directed by DCBS and DJJ. The facility's failure to implement and document the supervision provided to the patients placed these patients at risk for abuse.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure all patients received care in a safe setting for four of thirty-one sampled patients (Patients #11, #15, #18, and #26). Immediate Jeopardy was identified on 07/25/13, during a complaint investigation (KY20453). A plan of correction (POC) was received/accepted on 08/09/13, with a correction date of 08/03/13. A full survey was initiated on 08/13/13, which found the Immediate Jeopardy continued to exist, and further examples were identified. The facility failed to ensure the plan of correction was implemented and that Department for Community Based Services (DCBS) abuse prevention plans were followed. The facility failed to ensure Patients #11, #15, and #18 were supervised at all times when the patients' parents were present as required by DCBS. The facility failed to ensure a court order from the Department of Juvenile Justice (DJJ) was implemented for Patient #26.

In addition, the facility failed to ensure security cameras that were installed on 08/02/13 as part of the facility's POC were functioning.

The findings include:

A review of the policy titled "Child/Infant Requiring Social Service Interventions," dated 07/26/13, revealed that only when social issues are identified to include a history of drug abuse will staff order a consultation for Social Services and a drug screen for the infant. Findings of Social Services will be documented in their notes and communicated to staff caring for the infant. If DCBS is notified, documentation will be in the Social Services notes and on the discharge planning sheet on the infant's record.

The POC submitted by the facility which alleged compliance 08/03/13, was not implemented and staff education was ineffective. On 07/26/13, the facility developed a step-by-step guide entitled "Child/Infant Requiring Social Service Interventions" for personnel concerning the involvement of DCBS with the patients' care and the implementation of DCBS abuse prevention plans. Staff was educated to utilize the "Multidisciplinary Discharge Planning" nursing worksheet as a tool for: a) guidance for visitation (if indicated); b) appropriate discharge; and c) dissemination of information regarding visitation and discharge as well as any other DCBS directions to nursing staff and the manner in which this information is to be communicated from shift to shift. In addition, the POC stated staff was educated to ensure appropriate documentation of the visits and supervision of the visits in the infants' medical record and newborns required to have supervised visitation would be continuously monitored by nursing staff.

On 08/13/13 at 11:10 AM, interviews with staff revealed the facility's education regarding the "Child/Infant Requiring Social Service Interventions" policy was ineffective, as evidenced by: Staff was not knowledgeable of who was responsible for completing the nursing worksheet that was required to be utilized to provide guidance for visitation, to ensure appropriate discharge, and to ensure information regarding supervised visitation of the newborns, discharge, and any other DCBS directions was communicated to staff. Review of medical records for Patients #11, #15, #18, and #26 revealed DCBS abuse prevention plans and/or protection orders were not implemented per policy.

Interview with the Chief Nursing Officer (CNO) on 08/13/13, at 2:05 PM, revealed the facility screened all newborns and their mothers for drugs and if the screen was positive for the mother and/or baby, or if the mother appeared impaired, the facility notified DCBS of the findings of the drug screening and facility staff would supervise all visits with the newborn and mother until DCBS developed an abuse prevention/parenting plan. However, the information provided during interview conflicted with the "Child/Infant Requiring Social Service Interventions" policy dated 07/26/13.

Interview on 08/13/13, at 11:15 AM, with the Executive Director of Nursing (EDON) revealed that the facility's corrective action plan submitted on 08/09/13 stated the facility had developed a Multidisciplinary Discharge Planning policy. However, the interview revealed a newly developed Multidisciplinary Discharge Planning form was not a policy but a process. The newly developed Multidisciplinary Discharge Planning form was to be utilized by nursing staff along with the patient's care plan to ensure DCBS abuse prevention plans were implemented and followed for the safety of the patients. The EDON reported nursing staff received in-service education on the utilization of the Multidisciplinary Discharge Planning form; however, the facility failed to develop a written process that addressed who was responsible for completing specific sections of the form. A written process was developed and given to the survey team on 08/13/13.

1. The facility admitted Patient #11 on 08/11/13, with a diagnosis of Term Birth Living Child and a positive urine drug screen for marijuana. The facility contacted DCBS due to the patient's positive drug screen and DCBS developed interventions on the abuse prevention/parenting plan, including discharge instructions for supervision, to ensure the patient's safety after discharge. However, facility staff failed to document/include the details of the prevention/parenting plan developed by DCBS on the facility's discharge plan.

2. The facility admitted Patient #15 on 08/06/13, with a diagnosis of Term Birth Living Child and identified the patient to be at risk for Neonatal Abstinence Syndrome (group of problems that occur in newborns who were exposed to addictive or prescription drugs while in the mother's womb). On 08/06/13, at 11:30 PM, RN #2 informed the facility's social worker that the patient's drug screen was positive for Buprenorphine (an opioid) and the patient's meconium drug screen was pending. On 08/07/13, at 10:00 AM, the facility's social worker contacted DCBS to report the positive drug screen; DCBS accepted the case and instructed the facility social worker to continue supervised visits between mother and patient.

Documentation dated 08/07/13, at 3:00 AM, in the nursing notes revealed Patient #15 was bottle fed by the patient's mother. However, the location of the feeding was not documented. The nursing staff failed to document if the staff supervised the visit with the newborn as per the instructions of DCBS.

3. The facility admitted Patient #18 on 08/03/13, with a diagnosis of Term Birth Living Child and noted the patient was at risk for withdrawal from drugs. A review of nursing notes dated 08/05/13, at 9:00 AM, revealed Patient #18's father was to transport the baby at discharge. However, a review of the facility's social worker notes dated 08/05/13, at 2:00 PM, revealed DCBS developed an abuse prevention/parenting plan. According to the plan, Patient #18's father was not permitted to hold the patient and staff was to supervise visits with the patient by the parents. A review of nursing notes dated 08/05/13, at 5:20 PM, revealed DCBS assessed Patient #18 and instructed nursing staff to ensure the baby remained in the nursery and, when the parents visited the patient, the visits were to be supervised. Continued review of documentation revealed although the patient's parents visited the newborn numerous times at the facility, the facility failed to ensure staff had documentation to support visits were supervised as per DCBS abuse prevention plans for the protection of the newborn. The facility staff lacked clear delineation as to who was responsible for communicating the DCBS abuse prevention plans for newborns.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed the facility's social worker was responsible for ensuring appropriate discharge planning, including the DCBS discharge plan. RN #14 further stated that nursing staff was not always aware when DCBS came to the facility and that Patient #18's care plan had not been updated and revised to show the DCBS abuse prevention/parenting plan to ensure the infant's safety.

Interview with Social Worker #1 on 08

Based on interviews and reviews of medical records, Facility Plan of Correction, State Agency Abuse Prevention Plans, and the facility's policy it was determined the facility failed to ensure that each patient's rights were protected and promoted through nursing supervision by failing to ensure the facility's plan of correction was implemented and that Department for Community Based Services (DCBS) plans were followed to ensure patients were supervised at all times when the patients' parents were present as required by DCBS for two (Patients #15 and #18) of thirty-one medical records reviewed. The facility also failed to ensure a court order from the Department of Juvenile Justice (DJJ) was implemented for Patient #26.

The findings include:

An acceptable Plan of Correction (POC) was received on 08/09/13, alleging a correction date of 08/03/13. A review of the plan of correction revealed the facility implemented corrective actions including: On 07/26/13, developed a step-by-step guide entitled "Child/Infant Requiring Social Service Interventions" for personnel in regard to the involvement of DCBS with the patients' care and the implementation of DCBS abuse prevention plans. Staff was educated to utilize the Multiple Disciplinary Discharge Planning" nursing worksheet as a tool for a) guidance for visitation (if indicated); b) appropriate discharge; and c) dissemination of information regarding visitation and discharge, as well as any other DCBS directions to nursing staff and the manner in which this information is to be communicated from shift to shift. In addition, the plan of correction stated staff was educated to ensure appropriate documentation of the visits and supervision of the visits in the infant's medical record and newborns required to have supervised visitation would be continuously monitored by nursing staff.

Interviews with staff revealed the facility's education regarding "Child/Infant Requiring Social Service Interventions" policy was ineffective. Staff was not knowledgeable of who was responsible for completing the nursing worksheet that was required to be utilized to provide guidance for visitation, to ensure appropriate discharge, and to ensure information regarding visitation, discharge, and any other DCBS directions was communicated to staff. Review of medical records for Patients #15, #18, and #26 revealed DCBS abuse prevention plans and/or protection orders were not implemented per policy.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed that she had received training on the facility's newly developed drug screen policy for infants and on the facility's newly developed discharge planning form. The interview revealed the facility's social worker would request a copy from the patient's parent of the DCBS abuse prevention/parenting plan for patients with DCBS oversight. RN #14 stated there was a lack of communication between the facility staff and representatives from DCBS and, as a result, the facility did not always have the information related to the abuse prevention/parenting plan developed by DCBS.

Interview with the Chief Nursing Officer (CNO) on 08/13/13, at 2:05 PM, revealed the facility screened all newborns and their mothers for drugs and if the screen was positive for the mother and/or baby, or if the mother appeared impaired, the facility notified DCBS of the findings of the drug screening and facility staff would supervise all visits with the newborn and mother until DCBS developed an abuse prevention/parenting plan. However, the information provided during interview conflicted with the "Child/Infant Requiring Social Service Interventions" policy, dated 07/26/13. The facility policy did not detail that all newborns and mothers would be screened for drugs.

Interview on 08/13/13, at 11:15 AM, with the Executive Director of Nursing (EDON) revealed that even though the facility's corrective action plan submitted on 08/09/13 stated the facility had developed a Multidisciplinary Discharge Planning policy, the policy had not been developed/completed. However, the interview revealed the newly developed Multidisciplinary Discharge Planning form was not a policy but a process. The newly developed Multidisciplinary Discharge Planning form was to be utilized by nursing staff along with the patient's care plan to ensure the DCBS abuse prevention plan was implemented and followed for the safety of the patients. The EDON reported nursing staff received in-service education on the utilization of the Multidisciplinary Discharge Planning form. However, the facility failed to develop a procedure that addressed who was responsible for completing the specific sections of the form.

1. Medical record review revealed the facility admitted Patient #15 on 08/06/13, with a diagnosis of Term Birth Living Child and risk for neonatal abstinence syndrome (group of problems that occur in newborns who were exposed to addictive or prescription drugs while in the mother's womb). Review of the nursing notes dated 08/06/13, at 11:30 PM, revealed RN #2 contacted the facility social worker regarding the patient's positive buprenorphine drug screen, and that the patient's meconium drug screen was pending. On 08/07/13, at 10:00 AM, the facility social worker consulted DCBS to report the positive buprenorphine drug screen. DCBS accepted the case and instructed the facility social worker to continue to supervise visits between mother and patient. A nursing note dated 08/07/13, at 3:00 AM, revealed Patient #15 was bottle fed by mom but the location of the feeding was not documented and the charting graph was left blank. The facility failed to ensure the mom was supervised during visits with the newborn as per DCBS instructions. In addition, the nursing note dated 08/07/13, at 8:30 AM, revealed the patient was bottle fed by mom, but contained no documentation of location or nursing supervision.

2. The facility admitted Patient #18 on 08/03/13, with a diagnosis of Term Birth Living Child and risk for withdrawal from drugs. Review of the facility social worker notes dated 08/05/13, at 2:00 PM, revealed DCBS developed an abuse prevention/parenting plan. A review of the abuse prevention/parenting plan for Patient #18 revealed DCBS required staff to supervise visits with the mother and father and not allow the patient's father to hold the infant patient. However, a nursing note dated 08/05/13, at 9:00 AM, revealed Patient #18's father was to transport the baby at discharge. The nursing note dated 08/05/13, at 5:20 PM, revealed DCBS saw Patient #18 and instructed nursing staff to ensure the baby remained in the nursery and that visits with the baby were supervised by staff in the nursery. A review of Patient #18's record revealed no evidence staff supervised parental visits with Patient #18 on 08/05/13, at 6:00 PM and 9:00 PM. In addition, there was no documentation of supervision when the parent visited on 08/06/13, at 12:00 AM and 3:10 AM.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed DCBS did not provide the facility with a copy of their recommendations. However, according to RN #14, the facility social worker obtained copies of the abuse prevention/parenting plans from the mother of those infants involved with DCBS and placed copies in the medical records. RN #14 stated the social worker was responsible for ensuring appropriate discharge planning. RN #14 further stated that nursing staff was not always aware when DCBS came to the facility and/or when abuse prevention plans had been developed by DCBS. The interview gave no explanation why Patients #15 and #18's care plans had not been updated and revised to show a DCBS abuse prevention/parenting plan to ensure the infants' safety/supervision.

Social Worker #1 stated in interview on 08/13/13, at 11:15 AM, that staff notified the facility social worker when babies tested positive for drugs and/or showed signs and symptoms of drug withdrawal. According to Social Worker #1, a referral was made to DCBS by the facility social worker. Social Worker #1 stated a new discharge plan was revised to show discharge instructions for infant

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure nursing staff developed, and kept current, a nursing care plan related to Safety and Supervision for four of thirty-one sampled patients (Patients #11, #15, #18, and #26).

The findings include:

Review of facility policy titled "Patient Assessment/Reassessment," revised 07/13/13, revealed "an individualized plan of care would be developed, documented and provided in coordination with the patient family or designated individual." The policy also revealed "integration and interventions of other disciplines from the identified needs during the initial assessments would be reviewed or revised as care dictated." According to the policy, "the plan was to be updated as appropriate following changes in the patient's condition."

The facility conducted routine drug screenings of Patients #11, #15, and #18 during the course of their hospitalization and identified the patients as being positive for and/or at risk for withdrawal from controlled substances including narcotics and opioids. The facility notified the Department for Community Based Services (DCBS) of the results of the patients' drug screens and DCBS assessed and provided direction related to the required supervision during the hospitalization and discharge planning.

1. The facility admitted Patient #11 on 08/11/13, with a diagnosis of Term Birth Living Child and identified the patient had a positive urine drug screen for marijuana. DCBS developed and provided the facility with an abuse prevention/parenting plan related to the safety/supervision; however, the facility failed to ensure the interventions recommended on the abuse prevention/parenting plan were incorporated in the nursing care plan.

Interview with RN #14 on 08/13/13, at 11:25 AM, revealed that Patient #11 had DCBS involvement but the only way the facility obtained the abuse prevention/parenting plan was for the facility social worker to request a copy from Patient #11's mother. RN #14 revealed if the mother had not allowed the facility to copy the DCBS plan the facility would not have been aware of the required supervision for the safety of Patient #11. The interview revealed there was a lack of communication between facility staff and DCBS, regarding the abuse prevention plan, in order to appropriately care plan Patient #11 related to supervision during visits.

2. The facility admitted Patient #15 on 08/06/13, with a diagnosis of Term Birth Living Child and identified the patient to be at risk for Neonatal Abstinence Syndrome. On 08/06/13, at 11:30 PM, RN #2 informed the facility's social worker the patient's drug screen for Buprenorphine (an opioid) was positive. On 08/07/13, at 10:00 AM, the social worker contacted DCBS to report the positive drug screen and DCBS accepted the case for investigation, according to the social worker's progress note. A review of documentation in the medical record revealed DCBS informed the facility social worker to continue to supervise visits between mother and patient. However, a review of documentation revealed there was no evidence the recommendations of supervision had been incorporated in the care plan.

3. The facility admitted Patient #18 on 08/03/13, with a diagnosis of Term Birth Living Child and identified the patient to be at risk for withdrawal from drugs. A review of nursing notes dated 08/05/13, at 9:00 AM, revealed that the father of the baby was to transport the baby at discharge. However, a review of the facility's social worker notes dated 08/05/13, at 2:00 PM, revealed DCBS developed an abuse protection/parenting plan that stated the patient's father was not to hold the baby and the baby could not be unsupervised with the mother or father. However, the nurse's notes on 08/05/13, at 5:20 PM, revealed DCBS saw Patient #18 and instructed staff to ensure the baby remained in the nursery and that the parents were to only visit the baby in the nursery. There was no evidence found that nursing staff had updated/revised Patient #18's care plan to show DCBS updates.

Interview with RN #14 on 8/13/13, at 11:25 AM, revealed the facility social worker was responsible for obtaining copies of the abuse prevention/parenting plans from the mothers of those infants involved with DCBS. According to RN #14, the social worker was responsible for ensuring appropriate discharge planning. RN #14 further stated that Nursing was not always aware when DCBS came to the facility. RN #14 gave no explanation for why Patient #18's care plan had not been updated and revised to show DCBS recommendations to ensure the infant's safety.

Interviews with Nursing and Social Services were conflicting. Interview with Social Worker #1 on 08/13/13, at 11:15 AM, revealed the facility social worker was called when babies showed positive for drugs and/or showed signs and symptoms of drug withdrawal. According to Social Worker #1, a referral was made to DCBS by the facility social worker. Social Worker #1 stated a new discharge plan had been revised to show discharge instructions for infants involved with DCBS. The Social Worker stated nursing staff was responsible for ensuring appropriate discharge for the mom and baby.

4. The facility admitted Patient #26 on 08/16/13, with diagnoses of Drug and Alcohol Abuse, Attention Deficit/Hyperactivity Disorder, Depression, and Suicidal Attempts. Documentation revealed Patient #26 had been removed from the home and was committed to the Department of Juvenile Justice (DJJ). Further review revealed the patient was admitted to the adolescent psychiatric unit for safety and stabilization after being medically cleared. Review of the social history revealed the patient was currently on home incarceration and in the custody of the mother but custody had been removed several times and the patient was placed under the care of the state. Review of the court order entered 08/12/08, revealed Patient #26 was to have no unsupervised contact with the mother.

Review of the court order dated 10/02/10, revealed the patient had been charged with Fourth Degree assault of the mother. Review of the court order entered 08/21/12, revealed Patient #26 had been removed from the home and committed to DJJ. Patient #26 was detained pending placement and to be released to DJJ. A review of the behavioral health therapy notes dated 08/18/13, revealed DJJ was involved in the patient's care and that the patient had a probation and parole officer but continued to live with the mother.

According to the behavioral health daily therapy note, the primary treatment team was to involve necessary parties regarding disposition and safety planning. Review of the nursing care plan dated 08/17/13, revealed no evidence that nursing staff was aware Patient #26 was under DJJ custody. Review of the behavioral health treatment plan dated 08/17/13, revealed staff had identified Patient #26 was on house arrest for assault with a court date of 08/20/13. However, there was no documentation in the behavioral health treatment plan that Patient #26 was court ordered to be released to DJJ upon discharge.

Interview with RN #11 on 08/19/13, at 1:20 PM, revealed RN #11 was responsible for the care and safety of Patient #26. RN #11 was aware that Patient #26 had a court date scheduled for 08/20/13. RN #11 stated she was unsure if the mother would be transporting Patient #26 to court or if the mother would be going to court for the patient. RN #11 stated the DJJ worker came to the facility that morning (08/19/13) at 8:00 AM, and left the court order paperwork showing the patient had been placed in DJJ custody. However, there was no documentation that the information related to the court order had been added to Patient #26's care plan and the RN stated, "I didn't know I was supposed to do that." In addition, the Behavioral Health Treatment Plan initiated by Social Services on 08/17/13 failed to include DJJ's involvement.

Interview with the Director of Behavioral Health on 08/21/13, at 10:45 AM, revealed Social Services normally conducted discharge