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Based on interview and document review, the hospital did not have an effective governing body that carried out the functions required of a governing body to ensure hospital-wide oversight of quality assessment and performance improvement (QAPI), Nursing Services, and Dietary Services related to the following:

Ineffective Nursing Standards of Care as evidenced by; incomplete Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, lack of detoxification vital signs (alcohol and drug withdrawal) and Aggressive Behavior Assessments, lack of Physician's orders implemented for; supplemental drink, intake and output, and laboratory tests, expired inventory located in Nursing unit Code Blue kits, lack of patient's monitored by staff while in the Group room, and lack of Nursing Care Plan development/implementation. (A-395, A-396).

There was no documented evidence related to the Data collection of Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, and Aggressive Behavior Assessments to ensure the completion of assessments at every shift was sustained. (A273).


The cumulative effect of these systemic problems resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body and failure to provide a safe environment for patients.

Based on observation, interview, record, and document review, the hospital failed to develop, implement, and maintain an effective ongoing system for monitoring hospital-wide indicators which focused on quality assessment and performance improvement (QAPI) related to the following:

Ineffective Nursing Standards of Care as evidenced by; incomplete Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, lack of detoxification vital signs (alcohol and drug withdrawal) and Aggressive Behavior Assessments, lack of Physician's orders implemented for; supplemental drink, intake and output, and laboratory tests, expired inventory located in Nursing unit Code Blue kits, lack of patient's monitored by staff while in the Group room, and lack of Nursing Care Plan development/implementation. (A-395, A-396).

There was no documented evidence related to the Data collection of Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, and Aggressive Behavior Assessments to ensure the completion of assessments at every shift was sustained. (A273).

The cumulative result of these failures, did not ensure this Condition of Participation was met.

Based on interview, record, and document review, the hospital failed to ensure data was collected related to the completion of Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, and Aggressive Behavior Assessments. The lack of data collection did not ensure staff and health care providers accurately documented patients assessments in an effort to monitor and sustain effective treatment goals and outcomes.

Findings:

1a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 1, 2, 3, 11, 13, 14, and 16's medical records were reviewed for shift assessments. Each chart contained a document entitled Nursing Night Shift Chart Audit. The document did not indicate auditing for completion of assessments (with the exception of admission assessment) related to Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, and Aggressive Behavior Assessments.

Patient 1 was admitted to the hospital on 8/3/18 with diagnoses which included Assault Precautions Level III (harm to others) according to the admitting Physician orders.

Patient 1's RN (Registered Nurse) Daily Shift Assessment was not documented as completed on 8/6/18 during the 3pm-11pm shift and not fully completed during the 11pm-7am shift.

1b. Patient 2 was admitted to the hospital on 8/4/18 with diagnoses which included Suicide and Assault Precautions Level III (harm to self and others) according to the admitting Physician orders.

Patient 2's RN Daily Shift Assessment was not fully documented as completed on 8/7/18 during the 11pm-7am shift.

1c. Patient 3 was admitted to the hospital on 7/23/18 with diagnoses which included Suicide Precautions Level III according to the admitting Physician orders.

Patient 3's RN Daily Shift Assessment was not fully documented as completed on 7/29/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; 8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; 8/6/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; and 8/7/18 during the 7am-PM shift and 11pm-7am shift.

1d. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's RN Daily Shift Assessment was not documented as fully completed on 8/3/18-8/4/18 and on 8/6/18-8/8/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

1e. Patient 13 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III (harm to self) according to the admitting physician orders.

Patient 13's RN Daily Shift Assessment was not documented as fully completed on 8/2/18, 8/4/18 and 8/7/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shifts and on 8/5/18 during the 11pm-7am shift.

1f. Patient 14 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III according to the admitting physician's orders.

Patient 14's RN Daily Shift Assessment was not documented as fully completed on 8/1/18-8/5/18
during the 7am-PM shift, PM-11pm shift, 11pm-7am shifts.

1g. Patient 16 was admitted to the hospital on 8/6/18 with diagnoses which included alcohol and opioid withdrawal according to the admitting physician's orders.

Patient 16's RN Daily Shift Assessment was not documented as fully completed on 8/7/18 and 8/8/18
during the 11pm-7am shifts.

2a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 2, 3, 11, 13, and 14's medical records were reviewed for suicide and assault precaution assessments.

Patient 2 was admitted to the hospital on 8/4/18 with diagnoses which included Suicide and Assault Precautions Level III (harm to self and others) according to the admitting Physician orders.

Patient 2's Suicide Risk Assessment page 1 of 2, was not documented as completed on 8/6/18 during the PM-11pm shift. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 8/6/18 and 8/7/18 indicated Patient 1 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment for the following days: On 8/6/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; and 8/7/18 during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2b. Patient 3 was admitted to the hospital on 7/23/18 with diagnoses which included Suicide Precautions Level III according to the admitting Physician orders.

Patient 3's Suicide Risk Assessment page 1 of 2, was not documented as completed on 7/25/18 during the PM-11pm shift, and 8/5/18 during the PM-11pm shift. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 7/24/18-8/7/18 indicated Patient 3 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment from 7/24/18-8/7/18 (excluding 8/6/18 PM-11pm shift) during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2c. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's Suicide Risk Assessment page 1 of 2, was not documented as completed on 8/3/18 during the 7am-PM shift and PM-11pm shift, 8/4/18 during the 11pm-7am shift; 8/5/18 during the 11pm-7am shift, 8/6/18 during the 11pm-7am shift, and 8/7/18 during the 11pm-7am shift.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment from 8/3/18-8/7/18 (excluding 8/5/18 7am-PM shift) during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2d. Patient 13 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III (harm to self) according to the admitting physician orders.

Patient 13's Suicide Risk Assessment page 1 of 2, was not documented as completed on 8/2/18 during the 11pm-7am shift.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment on 8/2/18 during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2e. Patient 14 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III according to the admitting physician's orders.

Patient 14's Suicide Risk Assessment page 1 of 2, was not documented as fully completed on
8/3/18-8/4/18 during the PM-11pm shift and 11pm-7am shifts.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment on 8/3/18-8/4/18 during the PM-11pm shift and 11pm-7am shifts.

3a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 11, 13, 14, and 16's medical records were reviewed for pain assessments.

3b. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's RN Daily Shift Pain Assessment was not documented as completed on 8/3/18 during the 7am-PM shift and 11pm-7am shift, 8/4/18-8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift, 8/6/18 during the 7am-PM shift, and 8/7/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

3c. Patient 13 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III (harm to self) according to the admitting physician orders.

Patient 13's RN Daily Shift Pain Assessment was not documented as completed on 8/2/18, 8/4/18 and 8/7/18 during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts, and 8/5/18 during the 11pm-7am shift.

3d. Patient 14 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III according to the admitting physician's orders.

Patient 14's RN Daily Shift Pain Assessment was not documented as completed on 8/1/18-8/5/18
during the 7am-PM shift, PM-11pm shift, 11pm-7am shifts.

3e. Patient 16 was admitted to the hospital on 8/6/18 with diagnoses which included alcohol and opioid withdrawal according to the admitting physician's orders.

Patient 16's RN Daily Shift Pain Assessment was not documented as completed on 8/7/18 during the 7am-PM shift and 11pm-7am shift and on 8/8/18 during the 11pm-7am shift.

4a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 1, 2, and 11's medical records were reviewed for daily aggression risk assessments.

Patient 1 was admitted to the hospital on 8/3/18 with diagnoses which included Assault Precautions Level III (harm to others) according to the admitting Physician orders.

Patient 1's Daily Aggression Risk Assessment page 1 of 2, was not documented as completed on 8/4/18 and 8/6/18 during the PM-11pm shifts. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 8/4/18-8/6/18 indicated Patient 1 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Daily Aggression Risk Assessment related to clinical observations as indicated on page one of the assessment for the following days: On 8/4/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; 8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; and 8/6/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

4b. Patient 2 was admitted to the hospital on 8/4/18 with diagnoses which included Suicide and Assault Precautions Level III (harm to self and others) according to the admitting Physician orders.

Patient 2's Daily Aggression Risk Assessment page 1 of 2, was not documented as completed on 8/5/18 during the PM-11pm shift. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 8/5/18 and 8/7/18 indicated Patient 1 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Daily Aggression Risk Assessment related to clinical observations as indicated on page one of the assessment for the following days: On 8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift and 8/7/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

4c. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's Daily Aggression Risk Assessment page 1 of 2, was not documented as completed on 8/3/18, 8/4/18, 8/5/18, 8/6/18, and 8/7/18 during the 11pm-7am shifts.

On 8/9/18 at 2:30 P.M., a QAPI interview was conducted with Leadership. During the interview, the Director of Quality stated he reviewed the Nursing Night Shift Chart Audits. Additionally he stated Leadership met with staff individually when lack of Nursing admission assessment documentation was identified however, there was no discussion with staff related to the lack of documentation for Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, and Aggressive Behavior Assessments. Furthermore, the Director of Nursing (DON) acknowledged the current audit tool did not collect data to ensure staff and health care providers accurately documented patients assessments in an effort to monitor and sustain effective treatment goals and outcomes.

Based on observations, interviews and record reviews, the hospital failed to identify opportunities for improvement and take action to improve performance in the Food and Nutrition Service Department when the department failed to identify multiple deficient practices observed during the survey as high risk, high volume, patient safety concerns. This failure to identify, collect data and take action to remediate these practice put the patients, staff and visitors at continued risk for foodborne illness decline in nutritional status. (Cross refer A749, A621, A392)

Findings:

1. During the course of the survey, food safety concerns were identified which included:
a. Cooked Time and Temperature Controlled for Safety (TCS) foods were not being monitored for safety
b. Unsafe food storage practices were noted in two nursing stations
c. The ice machine was not effectively cleaned, sanitized and maintained to ensure the ice for patients, staff and visitors was from a sanitary source.
d. Other equipment in the Food and Nutrition Service department (can opener and drainpipe air gaps) were not maintained in a sanitary manner to prevent cross-contamination of patient, staff and visitor food.

During an interview with the Director of Food and Nutrition Services (DFANS) and the RD on 8/8/18, at 3:20 P.M., the DFANS stated that both he and the RD conducted kitchen sanitation inspections weekly. The DFANS was unable to state why the deficient practices related the unsanitary conditions were identified during the survey despite these routine inspections.

The Quality Council Report - Dietary Department, 2nd Quarter (5/18 - 7/18) indicated 90 to 94 percent compliance results from the Safety and Sanitation Inspections in the department. The unsafe practice noted during the survey were not identified in these reports in order for remediation to occur.

2. During the survey, a review of Patient 4's medical record indicated the patient was identified to be at High Nutrition Risk on admission on the nursing assessment and screen. The patient did not receive a nutrition assessment by the RD despite experiencing significant weight loss during the admission.

A review of the Quality Council Report - Dietary Department, 2nd Quarter (5/18 - 7/18) for Clinical Nutrition Services indicated that the RD was collecting data on whether nutrition consults ordered as appropriate. The Dashboard Project did not indicate corrective actions plans to remediate the effectiveness of the system.

During an interview with the RD on 8/8/18, at 3:20 P.M., the RD stated that if the nursing staff or the physician did not order a consult, there was no other screening of the patients to determine if the was a need for a nutrition assessment. Therefore, Patient X did not have a nutrition assessment performed despite being identified as High Nutrition Risk and having experienced significant weight loss during the hospital stay.

During a further interview with the RD the same day, at 4:15 P.M., the RD stated that she did not review patient weight records unless a nutrition consult was ordered. The RD did not have a system to evaluate the nutrition status of patients who were not referred by physician or nursing staff. She further stated that a system to remediate this issue had not been considered.

During an interview with the Director of Quality (DQ) on 8/9/18, at 2:30 P.M., the DQ indicated that he was not aware of the above quality study issues.

Based on observation, interview, record, and document review, the hospital failed to ensure Nursing services were integrated into the hospital wide Quality Assurance Performance Improvement (QAPI) Program related to the following:

Ineffective Nursing Standards of Care as evidenced by; incomplete Nursing Shift Assessments, Pain Assessments, Suicide Risk Assessments, lack of detoxification vital signs (alcohol and drug withdrawal) and Aggressive Behavior Assessments, lack of Physician's orders implemented for; supplemental drink, intake and output, and laboratory tests, expired inventory located in Nursing unit Code Blue kits, lack of patient's monitored by staff while in the Group room, and lack of Nursing Care Plan implementation. (A-395, A-396).

The cumulative result of these failures, did not ensure this Condition of Participation was met.

Based on Interviews and record review, the hospital nursing staff failed to notify the Registered Dietitian (RD) when 1 of 30 sampled patient's (4) had a physician order for a Nutrition evaluation on admission. In addition, the nursing staff failed to inform the RD and the physician when Patient 4 lost over 5 pounds in one week. These failures resulted in a potentially avoidable decline in the nutrition status for Patient 4.

Findings:

A review of the medical record for Patient 4 indicated that the patient was admitted on 7/11/18 with diagnoses that included diabetes (high levels of sugar in the blood), chronic kidney disease and severely depressed. Patient 4 was a 71 year old female with multiple medical problems according to the History and Physical Examination dated 7/12/18.

A review of the Nursing Admission Assessment, dated 7/11/18, indicated Patient 4 had a Nutritional Screen Score of 20. The instructions on the form stated, "If Nutrition Screen score is > (greater than or equal to) 20 ....call physician to order nutrition consult."

A review of a separate form titled "Nutrition Screen" dated 7/11/18, and completed by nursing staff, indicated Patient 4 had nutrition risk factors that included: BMI (body mass index) indicating obesity, major GI (gastrointestinal) surgery within the past 6 months, nausea, vomiting, diarrhea, constipation for 3 days or more, sore mouth and chewing/swallowing problems. The Risk determination score was 7 and the directions indicated that a score of "3 or more = High Nutrition Risk." The box on the form labeled "RD to follow" was checked.

A review of the "Physician Admitting Orders" dated 7/11/18 indicated the box for "Evaluate for Nutritional" was checked, indicating a Nutritional consult was ordered. A check-box adjacent to this order on the form was instructions to the nursing staff to call and leave a message for the RD to communicate a physician order for a consult. This block was left blank.

During an interview with RN 31 on 8/8/18, at 3:00 P.M., she stated the box on the form that was left unchecked should have been checked indicating that the RD was informed of the consult order. RN 31 was unable to determine if the Nutritional Evaluation physician order was communicated to the RD.

During an interview with the RD on 8/8/18 at 4:00 P.M., she stated that the physician order for a Nutritional consult was not communicated via the voice mail system as required. She had reviewed the voice mail log and this consult was not on the log.

A review of Patient 4's medical record with RN 31 did not reveal a Nutrition Evaluation in the medical record. In addition, the weight record for Patient 4 showed weights recorded as follows:
7/11/18 - 182.6 pounds
7/15/18 - 183.2 pounds
7/22/18 - 177.6 pounds (5.6 pound weight loss in one week)
7/29/18 - 176.6 pounds

The medical record was reviewed with RN 31 who verified that there was no documentation that the RD or the physician were notified of weight loss. The nursing staff failed to identify a potential decline in the nutritional status even after Patient 4 was determined to be a "High Nutrition Risk" on initial assessment. There was no follow-up to ensure Patient 4 was evaluated by the RD so that intervention could be put in place to prevent a further decline in the patient's nutritional status.

During an interview with the RD on 8/8/18, at 4:15 P.M., the RD stated that she did not review patient weight records unless a nutrition consult was ordered. The RD did not have a system to evaluate the nutrition status of patients who were not referred by physician or nursing staff.

Based on interview, record review, and document review, the facility failed to ensure Nursing care was consistently provided in accordance with Nursing professional Standards of Care and hospital policies for 10 of 30 sampled patients related to the following:

1. Nursing shift assessments were not fully completed for 7 of 30 sampled patients (1, 2, 3, 11, 13, 14,16).
2. Suicide Risk assessments were not fully completed for 5 of 30 sampled patients (2, 3, 11, 13, 14).
3. Pain assessments were not fully completed for 4 of 30 sampled patients (11, 13, 14, 16).
4. Aggressive Behavior assessments were not fully completed for 3 of 30 sampled patients (1, 2, 11,).
5. Expired inventory was located in Nursing unit Code Blue kits.
6. Detox vital sign assessments were not completed as ordered by the physician for 4 of 30 sampled patients (11, 14, 16, 27).
7. Detox medications as ordered by the physician, were not implemented for 4 of 30 sampled patients (11, 14, 16, 27).
8. A Supplement drink was not administered as ordered by the physician for 1 of 30 sampled patients (11).
9. Patients were not directly monitored for safety in 1 of 2 Group rooms in the Psychiatric PICU.
10. Intake and output (measurement of fluids, medications, nutrition) were not completed as ordered by the physician and per facility policy for 2 of 30 sampled patients (11, 25).
11. Laboratory tests were not completed as ordered by the physician for 2 of 30 sampled patients (22, 26).

The cumulative result of these failures, did not ensure Nursing care was consistently provided in accordance with Nursing professional Standards of Care and hospital policies.

Findings:

1a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 1, 2, 3, 11, 13, 14, and 16's medical records were reviewed for daily shift assessments.

Patient 1 was admitted to the hospital on 8/3/18 with diagnoses which included Assault Precautions Level III (harm to others) according to the admitting Physician orders.

Patient 1's RN (Registered Nurse) Daily Shift Assessment was not documented as completed on 8/6/18 during the 3pm-11pm shift and not fully completed during the 11pm-7am shift.

1b. Patient 2 was admitted to the hospital on 8/4/18 with diagnoses which included Suicide and Assault Precautions Level III (harm to self and others) according to the admitting Physician orders.

Patient 2's RN Daily Shift Assessment was not fully documented as completed on 8/7/18 during the 11pm-7am shift.

1c. Patient 3 was admitted to the hospital on 7/23/18 with diagnoses which included Suicide Precautions Level III according to the admitting Physician orders.

Patient 3's RN Daily Shift Assessment was not fully documented as completed on 7/29/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; 8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; 8/6/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; and 8/7/18 during the 7am-PM shift and 11pm-7am shift.

1d. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's RN Daily Shift Assessment was not documented as fully completed on 8/3/18-8/4/18 and on 8/6/18-8/8/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

1e. Patient 13 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III (harm to self) according to the admitting physician orders.

Patient 13's RN Daily Shift Assessment was not documented as fully completed on 8/2/18, 8/4/18 and 8/7/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shifts and on 8/5/18 during the 11pm-7am shift.

1f. Patient 14 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III according to the admitting physician's orders.

Patient 14's RN Daily Shift Assessment was not documented as fully completed on 8/1/18-8/5/18
during the 7am-PM shift, PM-11pm shift, 11pm-7am shifts.

1g. Patient 16 was admitted to the hospital on 8/6/18 with diagnoses which included alcohol and opioid withdrawal according to the admitting physician's orders.

Patient 16's RN Daily Shift Assessment was not documented as fully completed on 8/7/18 and 8/8/18
during the 11pm-7am shifts.

2a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 2, 3, 11, 13, and 14's medical records were reviewed for suicide and assault precautions.

Patient 2 was admitted to the hospital on 8/4/18 with diagnoses which included Suicide and Assault Precautions Level III (harm to self and others) according to the admitting Physician orders.

Patient 2's Suicide Risk Assessment page 1 of 2, was not documented as completed on 8/6/18 during the PM-11pm shift. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 8/6/18 and 8/7/18 indicated Patient 1 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment for the following days: On 8/6/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; and 8/7/18 during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2b. Patient 3 was admitted to the hospital on 7/23/18 with diagnoses which included Suicide Precautions Level III according to the admitting Physician orders.

Patient 3's Suicide Risk Assessment page 1 of 2, was not documented as completed on 7/25/18 during the PM-11pm shift, and 8/5/18 during the PM-11pm shift. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 7/24/18-8/7/18 indicated Patient 3 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment from 7/24/18-8/7/18 (excluding 8/6/18 PM-11pm shift) during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2c. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's Suicide Risk Assessment page 1 of 2, was not documented as completed on 8/3/18 during the 7am-PM shift and PM-11pm shift, 8/4/18 during the 11pm-7am shift; 8/5/18 during the 11pm-7am shift, 8/6/18 during the 11pm-7am shift, and 8/7/18 during the 11pm-7am shift.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment from 8/3/18-8/7/18 (excluding 8/5/18 7am-PM shift) during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2d. Patient 13 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III (harm to self) according to the admitting physician orders.

Patient 13's Suicide Risk Assessment page 1 of 2, was not documented as completed on 8/2/18 during the 11pm-7am shift.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment on 8/2/18 during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

2e. Patient 14 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III according to the admitting physician's orders.

Patient 14's Suicide Risk Assessment page 1 of 2, was not documented as fully completed on
8/3/18-8/4/18 during the PM-11pm shift and 11pm-7am shifts.

In addition, there was no documented evidence on page two of the Suicide Risk Assessment related to clinical observations as indicated on page one of the assessment on 8/3/18-8/4/18 during the PM-11pm shift and 11pm-7am shifts.

3a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 11, 13, 14, and 16's medical records were reviewed for pain assessments.

3b. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's RN Daily Shift Pain Assessment was not documented as completed on 8/3/18 during the 7am-PM shift and 11pm-7am shift, 8/4/18-8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift, 8/6/18 during the 7am-PM shift, and 8/7/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

3c. Patient 13 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III (harm to self) according to the admitting physician orders.

Patient 13's RN Daily Shift Pain Assessment was not documented as completed on 8/2/18, 8/4/18 and 8/7/18 during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts, and 8/5/18 during the 11pm-7am shift.

3d. Patient 14 was admitted to the hospital on 7/31/18 with diagnoses which included Suicide Precautions Level III according to the admitting physician's orders.

Patient 14's RN Daily Shift Pain Assessment was not documented as completed on 8/1/18-8/5/18
during the 7am-PM shift, PM-11pm shift, 11pm-7am shifts.

3e. Patient 16 was admitted to the hospital on 8/6/18 with diagnoses which included alcohol and opioid withdrawal according to the admitting physician's orders.

Patient 16's RN Daily Shift Pain Assessment was not documented as completed on 8/7/18 during the 7am-PM shift and 11pm-7am shift and on 8/8/18 during the 11pm-7am shift.

4a. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

Patient 1, 2, and 11's medical records were reviewed for daily aggression risk assessments.

Patient 1 was admitted to the hospital on 8/3/18 with diagnoses which included Assault Precautions Level III (harm to others) according to the admitting Physician orders.

Patient 1's Daily Aggression Risk Assessment page 1 of 2, was not documented as completed on 8/4/18 and 8/6/18 during the PM-11pm shifts. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 8/4/18-8/6/18 indicated Patient 1 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Daily Aggression Risk Assessment related to clinical observations as indicated on page one of the assessment for the following days: On 8/4/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; 8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift; and 8/6/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

4b. Patient 2 was admitted to the hospital on 8/4/18 with diagnoses which included Suicide and Assault Precautions Level III (harm to self and others) according to the admitting Physician orders.

Patient 2's Daily Aggression Risk Assessment page 1 of 2, was not documented as completed on 8/5/18 during the PM-11pm shift. Furthermore, page 1 of 2 documentation during the 11pm-7am shifts on 8/5/18 and 8/7/18 indicated Patient 1 was asleep however, there was no indication whether the patient slept the entire shift or if there was any opportunity for documented assessment observations.

In addition, there was no documented evidence on page two of the Daily Aggression Risk Assessment related to clinical observations as indicated on page one of the assessment for the following days: On 8/5/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift and 8/7/18 during the 7am-PM shift, PM-11pm shift, 11pm-7am shift.

4c. Patient 11 was admitted to the hospital on 8/2/18 with diagnoses which included Suicide and Assault Precautions Level III according to the admitting Physician orders.

Patient 11's Daily Aggression Risk Assessment page 1 of 2, was not documented as completed on 8/3/18, 8/4/18, 8/5/18, 8/6/18, and 8/7/18 during the 11pm-7am shifts.

5. On 8/7/18 at 9 A.M., Tours of the Psychiatric Child/Adolescent Unit, Psychiatric Intensive Care Unit (PICU), and Psychiatric Adult Units were conducted.

The hospital's Nursing unit document entitled Oxygen Tank Check Record (documentation of the amount of oxygen in the tank) and containers labeled Code Blue Contents (equipment used during emergent life-threatening events) for the Psychiatric Child/Adolescent Unit, PICU, and Psychiatric Adult Units were reviewed.

The Oxygen Tank Check Record was not documented as verified by Nursing staff on 8/7/18 on the PICU and Psychiatric Adult Units. The oxygen amount documented on the Psychiatric/Adolescent Unit indicated 2000 pounds per square inch (psi-unit of measure) however, when verified, the tank reached 1500 psi.

The Code Blue Contents on the Psychiatric/Adolescent Unit contained an opened packaged adult nasal cannula (oxygen delivery tubing inserted into a patients nostrils), expired tounge depressors, dated 6/2015 (used to keep tounge away from airway and or teeth), expired sodium chloride (normal saline solution) dated 2/1/2017, and expired child automated external defibrillator (a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias-AED) pads dated 3/28/13. The Code Blue Contents on the Psychiatric Adult Unit did not contain an adult or child size nasal cannula and additionally, contained expired sodium chloride dated, 01/17. In addition, the Code Blue Contents on the PICU contained expired sodium chloride dated, 04/16.

On 8/7/18 at 10:30 A.M., an interview was conducted with the Department Coordinator Therapist (DCT) and RN 1. RN 1 stated the hospital expected oxygen tanks were replaced when the psi was at or below 1500. In addition, the DCT stated the hospital expected each Nursing unit maintained the Code Blue container Contents up to date.

On 8/8/18 at 11:20 a.m., an interview was conducted with the Department Coordinator Therapist (DCT) and RN 1. Both RN 1 and the DCT stated the hospital expected Nursing filled out patient assessments each shift in entirety in accordance with hospital policies and professional Nursing standards of practice.

In addition, there was no documented evidence on page two of the Daily Aggression Risk Assessment related to clinical observations as indicated on page one of the assessment for the following days: On 8/3/18-8/7/18 during the 7am-PM shift, PM-11pm shift, and 11pm-7am shifts.

On 8/8/18 at 11:20 a.m., an interview was conducted with the Department Coordinator Therapist (DCT) and RN 1. Both RN 1 anf the DCT stated the hospital expected Nursing filled out patient assessments each shift in entirety in accordance with hospital policies and professional Nursing standards of practice.

The hospital's Clinical Services-Standards of Nursing Practice, Revised 03/12, indicated the RN will assess the patient each shift to include physical, psychosocial, and safety needs.

The hospital's Clinical Services Policy-RN Clinical Progress Note, Revised 4/14, indicated "1. All areas on the RN Daily Shift Assessment will be completed for each 8 hour shift. Areas are not to be left blank."

The hospital's Clinical Services Policy-levels of Observation, Revised 4/14, indicated "III. Level III-Suicide or Assault Precautions III...Patient assessment indicates a safety risk that cannot safely be managed with routine observations...C. Documentation: 1. A Daily Suicide/Assault Risk Assessment shall be completed by the assigned RN every shift. This note shall include the patient's behavior, condition, mood, and conversation as they relate to the patient's identified safety risk(s)."

6 a. Patient 11 was admitted to the facility on 8/2/18 at 6 P.M., per the Facesheet.

On Admission, Patient 11's physician ordered detox VS every 4 hours for the 1st day and 4 times a day thereafter.

Per the Nursing Admission Assessment, dated 8/2/18 at 6:45 P.M., the LN documented VS for Patient 11.

According to the Detoxification/Observation Flowsheets (forms for the staff to document vital signs):

On 8/2/18 the next set of VS for Patient A were documented at 8 P.M. (1.25 hours after the 1st set) and there were no other VS documented on 8/2/18.

On 8/3/18, Patient A's VS were assessed at 6 A.M., which was 10 hours from the previous set of VS and on 8/3/18 the staff only assessed Patient 11's VS 3 times, instead of the 4 times as ordered.

On 8/4/18, there were only 2 recorded sets of VS. At 6 A.M., the staff documented Patient 11 refused VS assessment and at 10 A.M., the staff documented Patient 11 was, "sleeping" and no VS were recorded.

On 8/6/18 and on 8/7/18 there were only 2 sets of VS documented. On those dates, at 6 & 10 A.M., the staff documented Patient 11 was, "sleeping," and no VS were recorded.

6 b. Patient 14 was admitted to the facility on 7/31/18 at 11:45 A.M., per the Facesheet.

On Admission, Patient 14's physician ordered detox VS every 4 hours for the 1st day and 4 times a day thereafter.

According to the undated and untimed Nursing Admission Assessment, a partial set of VS was documented. The VS assessment did not include a temperature or an oxygen saturation (amount of oxygen in the blood).

The next set of VS documented for Patient 14 was at 6 P.M. on 7/31/18. There were no other documented VS for Patient 14 on 7/31/18.

According to the Detoxification/Observation Flowsheets the staff next assessed Patient 14's VS at 6 A.M. on 8/1/18 which was 12 hours from the previous VS assessment.

6 c. Patient 16 was admitted to the facility on 8/6/18 at 7:28 P.M., per the Facesheet.

On Admission, Patient 16's physician ordered detox VS every 4 hours for the 1st day and 4 times a day thereafter.

According to the Detoxification/Observation Flowsheets the staff documented VS for Patient 16 at 8 P.M. on 8/6/18. There were no other documented vital signs on 8/6/18. The next set of VS assessed for Patient 16 was on 8/7/18 at 6 A.M., which was 10 hours after the previous set.

The DON stated in an interview on 8/8/18 at 2:50 P.M., the staff were supposed to assess VS as ordered by the physician and attempt to wake a sleeping patient to obtain VS. The DON also said if an attempt was made to obtain the VS while a patient was sleeping and the patient refused, the staff should document, "refused" on the Detoxification/Observation Flowsheets instead of "sleeping."

6 d. Patient 27 was admitted to the hospital on 7/17/18 with a diagnosis of opioid dependence, per the Facesheet.

The medical record was reviewed on 8/9/18. On 7/17/18, the physician ordered detox VS for Patient 27 every four hours for the first day.

According to the Detoxification/Observation Flow Sheet, Patient 27's VS were taken at 8 P.M. on 7/17/18. There were no VS taken again until 6 A.M. on 7/18/18, ten hours later.

During an interview on 8/8/18 at 4:20 P.M., LN 1 stated nursing staff should wake the patient up to do VS every four hours for the first 24 hours after admission.

According to the facility policy, entitled Vital Signs and last reviewed on 4/14, "All patients...will have vital signs taken BID unless the physician orders the vital signs to be taken more frequently and/or based upon individual needs." In addition, per the policy, "All vital signs are recorded on the patient's chart."

According to the hospital's policy, Acknowledgement of Orders, dated 4/14, "It is the policy of [hospital] to provide a process for physician orders to be noted and implemented ...All orders will be processed according to transcription and other medication administration orders."

7 a. Patient 11 was admitted to the facility on 8/2/18 at 6 P.M., per the Facesheet.

On admission, Patient 11's physician ordered Librium (medication used to treat alcohol withdrawal) Protocol for detox. Per the ordered Protocol:

On day 1 of the protocol "From time of admission to 8 A.M. the following morning," the nurses were to administer a dose of Librium every hour PRN complaints of tremors or anxiety, "or if Pulse is great than 100/minute or BP greater that 160 systolic or 100 diastolic."

At 8 P.M. on 8/2/18, the day of admission, the staff documented Patient 11's diastolic BP was 103. There was no documentation to reflect the patient received any Librium for the treatment of his elevated diastolic BP on 8/2/18 as ordered by the physician.

The DIPCDS stated on 8/8/18 at 10:55 A.M., the LNs should have administered Librium to Patient 11 on 8/2/18 for the patient's elevated BP.

RN 11 stated in an interview on 8/8/18 at 3:43 P.M., she was the charge nurse for the unit Patient 11 was housed on 8/2/18. RN 11 said the medication nurse should have been the person to medicate Patient 11 for the elevated blood pressure at 8 P.M. RN 11 said no one informed her that Patient 11 had an elevated diastolic blood pressure and was unable to determine who documented Patient 11's elevated blood pressure reading.

7 b. Patient 14 was admitted to the facility on 7/31/18 at 11:45 A.M., per the Facesheet.

On admission, Patient 14's physician ordered Librium (medication used to treat alcohol withdrawal) Protocol for detox. Per the ordered Protocol:

On day 2 and 3 of the protocol, the staff were supposed to administer a dose of Librium QID and every 2 hours PRN for complaints of tremor or anxiety, "or if Pulse is great than 100/minute or BP greater that 160 systolic or 100 diastolic."

On 8/2/18 (day 3) at 10 A.M., a facility staff member documented Patient 14's pulse was 105. There was no documentation to reflect the LNs administered Librium to the patient for the elevated pulse rate as ordered by the physician.

7 c. Patient 16 was admitted to the facility in the PICU on 8/6/18 at 7:28 P.M., per the Facesheet.

On admission, Patient 16's physician ordered Librium (medication used to treat alcohol withdrawal) Protocol for detox. Per the ordered Protocol:

On day 2 and 3 of the protocol, the staff were supposed to administer a dose of Librium QID and every 2 hours PRN for complaints of tremor or anxiety, "or if Pulse is great than 100/minute or BP greater that 160 systolic or 100 diastolic."

On 8/7/18 (day 2) at 8:50 A.M., a LN documented the administration of the routine Librium dose and at 9 A.M. a LN documented an as needed dose of Librium was administered to Patient 16. An hour later, at 10 A.M., a facility staff member documented Patient 16's diastolic blood pressure was 110 and the patient's heart rate was 127. There was no documentation to reflect Patient 16 received another PRN dose of Librium after the 2 hour time frame (11 A.M.), nor was there another assessment of the patient's blood pressure, pulse or other symptoms until 6 P.M. that evening.

On 8/8/18 at 9:30 A.M., Patient 16's physician documented in a progress note the patient had, "Severe, daily & constant alcohol withdrawal...elevated risk morbidity/mortality (sick/death) due to uncontrolled alcohol withdrawal...Continue Librium protocol; encouraged PRN's (as needed Librium doses)" In addition, per the same note, Patient 16's physician documented the justification for continued stay in the facility was, "Acute physiologic (normal body function) jeopardy (death, loss, or injury) due to severe withdrawal."

On 8/8/18 at 10:40 P.M., RN 11 documented in the 3 - 11 P.M. nursing narrative note Patient 16 complained of tremors and body aches during her shift and the patient was on the Librium protocol, however, there were no documented PRN doses of Librium administered to the patient for the symptoms

The DON stated in an interview on 8/9/18 at 4:05 P.M., after a joint review of Patient 16's medical record, the nurses should have administered PRN doses of Librium to the patient on the PM shift on 8/8/18.

7 d. Patient 27 was admitted to the hospital on 7/17/18 with a diagnosis of opioid dependence, per the Facesheet.

The medical record was reviewed on 8/9/18. On 7/17/18, the physician ordered a Clonidine Opioid Detox Protocol for Patient 27. Per the protocol, nursing staff were to administer Clonidine 0.1 mg by mouth to the patient every four hours while awake for the first 48 hours. The Clonidine Opioid Detox Routine Medications record indicated nursing gave the first dose at 9:30 P.M. on 7/17/18.

Documentation on the Patient Rounds/Observations sheet indicated Patient 27 was awake at 7 A.M. on 7/18/18, however there was no dose of Clonidine given until 10:05 A.M. The next dose administered was at 2 P.M. There were no further doses of Clonidine given while the patient was awake on 7/18/18.

Documentation on the Patient Rounds/Observations sheet indicated Patient 27 was awake at 5:45 A.M. on 7/19/18, however there was no dose of Clonidine given until 9:18 A.M. The next dose administered was at 2 P.M. There were no further doses of Clonidine given while the patient was awake on 7/19/18.

The DON stated during an interview on 8/9/18 at 3:40 P.M. nursing staff should have given Clonidine when the patient was first awake at 7 A.M. on 7/18/18 and 5:45 A.M. on 7/19/18. The DON acknowledged nursing staff did not administer Clonidine 0.1 mg to Patient 27 every four hours while awake as ordered.

According to the facility policy, entitled Administration of Medication, last reviewed on 4/14, "Properly prepare the medication for administration according to physician order..."

According to the hospital's policy, Acknowledgement of Orders, dated 4/14, "It is the policy of [hospital] to provide a process for physician orders to be noted and implemented ...All orders will be processed according to transcription and other medication administration orders."

8. Patient 11 was admitted to the facility on 8/2/18 at 6 P.M., per the Facesheet.

On admission, Patient 11's physician ordered a can of a nutritional supplement drink three times daily if the patient did not eat a meal.

The Nutrition Services Diet/Food Monitor Lists (a form to document the percentage of breakfast, lunch and dinner each patient consumed) were reviewed on 8/9/18. Per these forms, Patient 11 did not eat breakfast on 8/3/18, 8/4/18, 8/5/18 and 8/6/18. In addition, per these same forms Patient 11 did not eat lunch on 8/4/18, 8/5/18, and 8/7/18. Patient 11 did not eat dinner on 8/4/18 and 8/6/18.

Patient 11's MAR was reviewed on 8/7/18. The nutritional supplement drink order was listed on the MAR, but there was no documentation to reflect any was administered to the patient.

The DIPCDS stated on 8/8/18 at 10:55 A.M.., the nurses should have administered the supplement drink to Patient 11 for each meal missed.

9. During a tour of the facility, on 8/7/18 at 9 A.M. with the DIPCDS, the DIPCDS stated that no patients were ever allowed in any of the group rooms without staff present in the room.

During an observation in the PICU on 8/7/18 at 3:45 P.M., Patient 13 was observed alone in a group room without staff present in the room. The doors to the room were locked and required a key to enter and exit the room. The chairs in the group room had arms which posed a ligature (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) risk to patients.

BHS 1 who was outside the room in the hallway was interviewed at that time. BHS 1 stated patients were not supposed to be in a group room without staff present. BHS 1 acknowledged and identified the chair handles were a potential ligature point.

Patient 13 was admitted to the facility on 7/31/18, per the Facesheet.

According to the physician's Psychiatric Evaluation, dated 8/1/18, Patient 13 was admitted to the facility after having had a 2nd suicide attempt and was placed on suicide precautions in the PICU.

During another observation of the group room in the PICU on 8/8/18 at 8:08 A.M. with the DIPCDS there were 9 patients in the group room without staff present in the room. A short time later, the galley (small kitchen area off the group room) door opened and 2 staff were observed inside the room. The DIPCDS stated at that time, both staff should not have been in the galley at the same time. The DIPCDS also said, 1 staff member should have remained in the group room to observe the patients while the other tended to the needs in the galley.

10 a. Patient 11 was admitted to the facility on 8/2/18 at 6 P.M., per the Facesheet.

On admission, Patient 11's physician ordered I & O every shift.

On 8/7/18 at 11:20 A.M., a tour of the PICU with the DIPCDS was conducted. Observed on the unit was Patient 11 with a 1:1 sitter standing near the patient (BHS 2).

On 8/7/18 at 3:35 P.M., BHS 2 and RN 11 were interviewed. BHS 2 stated for a patient on I & O monitoring, the staff were supposed to provide a hat (device placed in the toilet to capture output for measuring). BHS 2 was unaware Patient 11 was on I & O monitoring and stated there wasn't a hat placed in the patient's toilet.

RN 11 confirmed what BHS 2 said and also said the person who was 1:1 monitor was supposed to document the amount of output obtained from the patient.

Patient 11's I & O forms were reviewed on 8/7/18. Between 8/3/18 and 8/6/18, there were no documented measurements of output for the patient on the forms except to note, "X 1" (times one) or, "X 2" (times 2) or zero. At the bottom of each form was a section for the staff to document the total fluid intake and output in a 24 hour period and, between 8/3/18 and 8/6/18, none of the 24 hour intake and output sections were completed.

According to the facility policy, entitled, Intake and Output, last reviewed on 4/14, the purpose was, "To provide an accurate and consistent method of recording fluid intake and output when ordered by the physician..." In addition, per the policy, "Measure all urine output, emesis (vomit), liquid stools, and drainage from other sources and record as output for each eight-hour shift...Each patient should have his/her own measuring container...The person recording the evening I & O will also record the 24-hour total."

10 b. Patient 25 was admitted to the hospital on 5/4/18 with a diagnosis of schizophrenia, per the Facesheet.

The medical record was reviewed on 8/8/18. According to a Medical Progress Record note, dated 7/5/18, the physician documented Patient 25's status as, "Failure to thrive. Has poor PO intake per nursing."

On 7/6/18, the physician ordered daily I & O measurements. The physician order was signed off by a licensed nurse. A licensed nurse also signed off that a 24 hour chart audit was completed. A review of the I & O record indicated there were no I & O's documented from 7/7/18 to 7/15/18, when the physician re-ordered I & O.

During an interview on 8/8/18 at 3:22 P.M., RN 1 stated that the patient's I & O should be documented and totaled each shift. RN 1 further stated the physician order for I & O should be communicated in report each shift. RN 1 acknowledged there was no documentation of Patient 25's I & O from 7/7/18 to 7/15/18.

According to the hospital's policy, Intake and Output, dated 4/14, "It is the policy of [hospital] to develop a consistent, accurate method of recording fluid intake and output." The policy further indicated, "Measure all urine output, emesis, liquid stools, and drainage from other sources and record as output for each eight hour shift ...Keep accurate record for intake for each eight hour shift."

In addition, according to the hospital's policy, Acknowledgement of Orders, dated 4/14, "It is the policy of [hospital] to provide a process for physician orders to be noted and implemented ...All orders will be processed according to transcription and other medication administration orders."

11 a. Patient 22 was admitted to the hospital on 7/11/18 with a diagnosis of Bipolar disorder, per the Facesheet.

The medical record was reviewed on 8/8/18. According to the physician's orders, dated 7/31/18, the physician ordered tests due to Patient 22's recent diarrhea, for stool culture (to detect the presence of disease-causing bacteria) and stool for C-diff (to detect Clostridium difficile, a bacteria that causes diarrhea).

There were no test results found in the medical record.

When interviewed on 8/8/18 at 8:45 A.M., the DON stated she was unable to locate the test result

Based on interview and record review, the facility failed to ensure the nursing care plan was implemented for the assessment of symptoms of withdrawal from alcohol abuse four times daily for 3 of 30 sampled patients (11, 14, 16).

Findings:

a. Patient 11 was admitted to the facility on 8/2/18 with diagnoses which included unspecified psychosis per the Facesheet.

On admission, Patient 11's physician ordered a medication administration protocol for the treatment of the patients alcohol abuse.

On 8/2/18 a facility staff member documented in a Substance Abuse Treatment Plan the nurses were supposed to monitor the patient's VS and physical symptoms to assess detox status and the need for medications four times a day.

Patient 11's Detoxification/Observation Flow Sheets were reviewed on 8/7/18. The Flow Sheets had sections for the staff/nurses to document a patient's VS and 12 other specific physical symptoms of withdrawal. The Flow Sheets were incomplete as follows:

On 8/2/18, there were VS documented at 8 P.M., however, the section for the nurses to document the assessment of the other physical symptoms was blank.

On 8/4/18, there were VS documented at 6 P.M., but the corresponding section to document physical symptoms was blank.

On 8/5/18, there were VS documented 3 times, at 10 A.M., 2 P.M., and 6 P.M. There was no documentation of Patient 11's physical symptoms at 10 A.M., or 6 P.M.

On 8/6/18, there were VS documented at 2 P.M. and 6 P.M., but there was no documented assessment of Patient 11's physical symptoms at 6 P.M.

On 8/7/18, there were VS documented at 2 P.M. and 6 P.M., but there was no documented assessment of Patient 11's physical symptoms at 2 P.M.

b. Patient 14 was admitted to the facility on 7/31/18 with diagnoses which included Bipolar disorder (alternating episodes of elation and depression) per the Facesheet.

On admission, Patient 14's physician ordered a medication administration protocol for the treatment of the patients alcohol abuse.

On 7/31/18, a facility staff member documented in a Substance Abuse Treatment Plan the nurses were supposed to monitor the patient's VS and physical symptoms to assess detox status and the need for medications four times a day.

Patient 14's Detoxification/Observation Flow Sheets were reviewed on 8/7/18. The Flow Sheets had sections for the staff/nurses to document a patient's VS and 12 other specific physical symptoms of withdrawal. The Flow Sheets were incomplete as follows:

On 8/1/18, there were VS documented at 6 A.M., 2 P.M., and 6 P.M. There was no documentation to show the nurses assessed the other physical symptoms for Patient 14 at 6 A.M. or 6 P.M.

On 8/2/18, there were 4 sets of VS documented, but only 1 documented set of physical symptoms assessed.

On 8/3/18, there were 4 sets of VS documented, but only 3 documented sets of physical symptoms assessed.

On 8/4/18, there were 4 sets of VS documented, but only 3 documented sets of physical symptoms assessed.

c. Patient 16 was admitted to the facility on 8/6/18 with diagnoses which included alcohol dependence per the Facesheet.

On admission, Patient 16's physician ordered a medication administration protocol for the treatment of the patients alcohol abuse.

On 8/6/18, a facility staff member documented in a Substance Abuse Treatment Plan the nurses were supposed to monitor the patient's VS and physical symptoms to assess detox status and the need for medications four times a day.

Patient 16's Detoxification/Observation Flow Sheets were reviewed on 8/8/18. The Flow Sheets had sections for the staff/nurses to document a patient's VS and 12 other specific physical symptoms of withdrawal. The Flow Sheets were incomplete as follows:

On 8/7/18, there were 4 sets of vital signs documented, but only 2 documented sets of physical symptoms assessed for Patient 16.

The DON stated in an interview on 8/8/18 at 2:50 P.M., the nurses were supposed to document on the Detoxification/Observation Flow Sheets the assessment of the physical withdrawal symptoms a patient had. The DON also said the forms were supposed to be entirely completed.

According to the facility policy, entitled, Guidelines for Charting, last reviewed 4/14, "It is the policy of [facility] that documentation of patient care must be performed and completed. The documentation shall be clear, concise, legible, and accurate.


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Patient 3 was admitted for alcohol detoxification. The Medical Record for patient 3 contained a form entitled "Intake Assessment." The form contained a section for pain level assessment that was left blank.

The Medical Records for patients 5, 6, and 7 contained RN Daily Shift Assessments that were missing pain level assessments. Patient 5 was admitted for treatment of depression. The record for patient 5 was missing a pain assessment on July 11, 2018 PM shift. Patient 6 was a teenager admitted for attempted suicide. The record for patient 6 was missing pain assessments for all three nursing shifts on June 13, 2018. Patient 7 was admitted for a diagnosis of schizoaffective disorder. The record for patient 7 was missing pain assessments for all three nursing shifts on May 21 and 23, 2018.

The hospital failed to ensure the Condition of Participation, CFR 482.28 Food and Dietetic Services, was met by failing to:

1. Develop a system for identifying, investigating and controlling infections by ensuring sanitary conditions in the Food and Nutrition Service department and the nursing pantries. (Cross refer A749)

2. Ensure the Director of Food and Nutrition Service was effective at safely managing the daily operations of the department. (Cross refer A620)

3. Ensure the nutrition needs of the patients were met by having a system to capture patients who were at nutrition risk but not triggered by nursing for a nutrition assessment. (Cross refer A392)

4. Have an effective quality assurance and performance improvement plan to remediate high risk, high volume patient safety and quality of care in the Food and Nutrition Service department. (Cross refer A283)

The cumulative effect of these systemic problems resulted in the failure of the hospital to deliver Food and Nutrition Services in a safe and effective manner in compliance with the Condition of Participation for Food and Dietetic Services.

Based on observations, interviews and record reviews, the Director of Food and Nutrition Service (DFANS) was not effective at safely managing the daily operations of the Food and Nutrition Service when:

1. The DFANS and the Registered Dietitian failed to ensure the Food and Nutrition Service staff safely cooled cooked Time and Temperature Controlled for Safety (TCS) foods, to prevent food borne illness. Time and Temperature Controlled for Safety (TCS) foods include foods that can result in food borne illness if not stored at temperatures to prevent this harmful growth of disease causing organisms. (Cross refer A749)

2. Safe food storage practices were not maintained in two of the nursing station food pantries (ASU 2 and ASU 3). (Cross refer A749)

3. The hospital's ice machine was not maintained in a sanitary manner. (Cross refer A749)

4. Essential equipment in the Food and Nutrition Services was not maintained in a sanitary manner when an air gap was not maintained for the ice machine, the warewashing sink and the food preparation sink. The can opener was not maintained to prevent cross contamination of containers requiring its use. (Cross refer A749)

5. The DFANS failed to maintain the required food supply to effectively implement the hospital's disaster food plan in the event of a widespread disaster. (Cross refer A703)

6. The Food and Nutrition Service Quality Assurance and Performance Improvement (QAPI) plan did not identify the deficient practices observed during the survey in order to develop opportunities for improvement with high volume, high risk processes unique to the department. (Cross refer A283 )

These failures had the potential to result in food borne illness in a patient population of 67; undernutrition for patients, staff and visitors during a widespread disaster; and, a lack of remediation of high risk, high volume deficient practices in the Food and Nutrition Services.

Findings:

1. Safe cooling of cooked TCS foods requires removing heat from food quickly enough to prevent microbial (bacterial) growth. Excessive time for cooling of TCS foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, TCS foods are subject to the growth of a variety of pathogenic (disease causing) microorganisms. The Food Code provision for cooling provides for cooling from 135 °F to 41 °F or 45 °F in 6 hours, with cooling from 135 °F to 70 °F in 2 hours. The initial 2-hour cool is a critical element of this cooling process (Food Code, 2017).

A review of the hospital's "Daily Cooking Log for Potentially Hazardous Foods [now known as TCS foods]" dated 7/25 through 8/6/18 indicated "Quinoa", a cooked TCS food, was cooled on 8/5/18. The log indicated the Quinoa was 170 °F at 12:00 and was 36 °F at 3:30, a three and a half hour gap where no other temperature monitoring was documented. There was no documentation that the Quinoa reached 70 °F within the required 2 hour timeframe.

Further review of the hospital's "Daily Cooking Log for Potentially Hazardous Foods" indicated instructions to the staff that stated "Chill cooked, hot foods using one of these methods: ..." The first method in the instruction was consistent with the Food Code requirements. The second method, the "One-Stage" method, indicated cooked, hot foods could be cooled "Directly from 135 °F to 40 °F within a total of 4 hours. The total cooling process from 135 °F to 40 °F may not exceed 4 hours ...."

This method does not ensure the initial 2 hour cool from 135 °F to 70 °F is met which according to the Food Code is a critical element because bacteria can grow to numbers sufficient to cause food borne illness in the temperature range after more than 2 hours. Additionally, dry food such as Quinoa become a TCS food when water is added and cooked (Food Code, 2017).

During a subsequent interview with the DFANS and the Registered Dietitian (RD) on 8/8/18, at 3:20 P.M., the RD reviewed the Daily Cooling Log from the previous day and indicated that she was unaware that Quinoa even required monitoring for cool down. She further stated that she worked with the DFANS to establish the instructions to the staff on the Daily Cooling Log. She was not aware that the instructions for the "One-Stage" method of cooling cooked, hot foods was inconsistent with requirements in the Food Code. She did not know that the initial 2 hour requirement was critical. The DFANS also indicated that he did not know that the instructions to the staff on the form were not correct.

Further review of the hospital's "Daily Cooling Logs for Potentially Hazardous Foods" dating back to January 17, [2018], showed that of 60 entries on the logs for cooling cooked foods, 35 entries did not document that the TCS food had been sufficiently cooled from 135 °F to 70 °F in the required 2 hours. In addition, four entries did not indicate that cooling monitoring had started when the food was at least 135 °F. The cooling log included food items such as stuffed peppers, ground beef, pork carnitas, turkey burgers, sausage links and chicken.

2. Except during preparation, cooking, or cooling ...Time and Temperature Control for Safety (TCS) food shall be maintained either at 135 °F or above or at 41 °F or less. Turkey is a TCS food. (Food Code, 2017).

During an observation in the ASU 3 nursing unit pantry on 8/7/18, at 2:45 P.M., two brown paper bags were noted in the cupboard. The bags were each labeled with a patient name and "2 P.M. snack". The bags were opened and inside each was a half of a turkey sandwich in a plastic baggie.

During a concurrent interview with the DFANS, he stated that the 2 P.M. snacks were delivered with the lunch at noon. He stated that the sandwiches should have been placed in the refrigerator in the pantry and maintained at 41 °F until they were served to the patients. He verified that the sandwiches were not cold and appeared to have been stored in the cupboard since lunch. He acknowledged that although the hospital's system was for the nursing staff to place the sandwiches in the refrigerator, it was the Food and Nutrition Service department's responsibility to ensure the food was safe to serve to the patients.

Also, during an observation in the ASU 3 nursing station pantry on 8/7/18, at 2:50 P.M., the thermometer used to monitor the refrigerator temperature registered 50 °F. The refrigerator contents included milks and yogurts used as snacks for the patients. The temperature of the milk was tested with a thermometer which register 50 °F. The yogurt registered 48.7 °F.

During a concurrent interview with the DFANS, he stated that it was the responsibility of the nursing staff to monitor the temperature of the pantry refrigerators on the Daily Nutrition Refrigerator/Freezer Temperature Log every morning. He further stated that the Food and Nutrition Service staff stock the pantry refrigerators daily.

A review of the "Daily Nutrition Refrigerator/Freezer Temperature Log" in the ASU 3 pantry dated August 2018 indicated that the temperature recorded for 8/7/18 was 46 °F, too high to maintain the TCS foods at 41 °F or less for safety. Upon further review, the instructions on the log stated, "Refrigerator temperature is to be maintained between 36 degrees and 46 degrees Fahrenheit ...."

During a concurrent interview with the DFANS, he could not explain why the safe temperature parameters on the form indicated that a range of 36 to 46 °F was acceptable. He verified that according to the form, the recorded temperature for that day was within the acceptable range and there was no action required. He verified the temperatures taken of the milk and yogurt and stated that they had not been stored at the safe temperature.

Also noted in the refrigerator during the same observation was a bowl that contained six "Uncrustable" peanut butter and jelly sandwiches. The manufacturer's package instructions on the sandwiches stated 'Keep Frozen, thaw for 30 to 60 minutes, eat within 8 to 10 hours." The bowl was labeled with an expiration date of 8/12/18, five days later. The sandwiches were not labeled with a date or time they were thawed. The DFANS stated that hid department delivered the sandwiches and dated the bowl with the expiration date. He was not aware of the manufacturer's instructions regarding the thawed shelf life of the sandwiches. He verified that the sandwiches should not be stored in the refrigerator unless they were monitored to be sure they were either consumed or discarded within 8 to 10 hours per manufacturer's instructions.

3. During an observation of the hospital's only ice machine in the kitchen on 8/7/18, at 9:50 A.M., a clean white napkin swipe of the bottom of the water trough in the icemaker produced a significant amount of a brown/black gelatinous residue. Also observed was a brown residue throughout the icemaker including the curtain, inside the water trough and on the rubber tubing. The DFANS verified these observations.

During a concurrent interview with the DFANS, he indicated that the residue observed throughout the icemaker was significant. Although the maintenance staff was responsible for cleaning the icemaker portion of the ice machine, there was no system for the DFANS to ensure that the icemaker was effectively cleaned to ensure the ice was safe for consumption by the patients, staff and visitors.

4. An air gap is the space between the end of a kitchen equipment drainpipe and the flood level of the drain sink. This space is required to be at least one inch or twice the diameter of the opening of the drainpipe. The purpose of an air gap is to prevent the backflow of sewage water from contaminating the drainpipe and the kitchen equipment with disease causing microorganisms (Food Code, 2017).

During an observation in the kitchen on 8/7/18, at 10:20 A.M., the end of the drainpipe from the ice machine's ice storage bin was noted in the floor drain sink. Also observed, the drainpipes from the warewashing sinks and the food preparation sinks were not maintaining an air gap.

During a concurrent interview with the Director of Plant Operations (DPO), he stated that there should be an air gap maintained at all three of these equipment drainpipes. He stated that the pipes may have been knocked out of place during cleaning.

During a concurrent interview with the DFANS, he was not aware that an air gap was required. He verified that there was no system for identifying and resolving issues with the air gaps.

Also, during an observation in the kitchen on 8/7/18, at 9:36 A.M., the table mounted can opener was noted to contain a significant amount of a black sticky residue around the blade, the gears of the can opener and all around the base that holds the can opener. In addition, the blade was worn and nicked so that it was no longer a smooth surface.

During a concurrent interview with the Director of Food and Nutrition Service (DFANS), he stated that the can opener was cleaned weekly. He also stated that the blade was not changed on a regular basis but as needed. He could not explain why the can opener was not clean. He further could not explain how the dirty can opener could prevent cross contamination that could result in food borne illness when opening cans of food for the patients and staff.

According to the 2017 Food Code, equipment food-contact surfaces and utensils shall be clean to sight and touch. Additionally, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Moreover, cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened.

5. During a concurrent observation of the disaster food supplies, interview with the Director of Food and Nutrition Service (DFANS) and review of the hospital's "Dietary Disaster Plan" (revised 8/15) on 8/8/18, at 8:50 A.M., the hospital's disaster food supplies were reviewed. The hospital's plan required 13 cases of 100 each, 0.5-ounce peanut butter packets. The hospital had one and a half cases of the peanut butter packets. The DFANS verified that they did not have adequate peanut butter in the event of widespread disaster. He verified that the disaster food supplies should be on hand at all times in order to remain self-sufficient in case the hospital was required to shelter in place with no deliveries of food supplies. The "Disaster Menu" relied on peanut butter as a source of protein for two days of the menu.

During this same observation, interview and record review, the hospital's disaster plan required eight number 10 cans of white beans (each number 10 can contained approximately 12 cups of beans). The hospital has three number 10 cans. The DFANS verified that the white beans were on the disaster menu to add protein to a lunch entrée. The DFANS could not explain why these disaster supplies were not available or how the hospital would meet the nutritional needs of the patients, staff and visitors in the event of a widespread disaster in which deliveries of additional food supplies was not possible.,


6. The DFANS failed to identify opportunities for improvement and take action to improve performance in the Food and Nutrition Service Department when the department failed to identify multiple deficient practices observed during the survey as high risk, high volume, patient safety concerns. This failure to identify, collect data and take action to remediate these practice put the patients, staff and visitors at continued risk for foodborne illness decline in nutritional status. (Cross refer A283).

During an interview with the Director of Food and Nutrition Services (DFANS) and the RD on 8/8/18, at 3:20 P.M., the DFANS stated that both he and the RD conducted kitchen sanitation inspections weekly. The DFANS was unable to state why the deficient practices related the unsanitary conditions were identified during the survey despite these routine inspections.

The Quality Council Report - Dietary Department, 2nd Quarter (5/18 - 7/18) indicated 90 to 94 percent compliance results from the Safety and Sanitation Inspections in the department. The unsafe practice noted during the survey were not identified in these reports in order for remediation to occur.

Based on observations, interviews and record reviews, the hospital failed to ensure the registered dietitians adequately supervised the nutritional aspects of patient care. This resulted in a failure to meet the nutritional needs of the 67 patients when registered dietitians failed to:

1. Identify one of 30 sampled patient's (4) at nutrition risk for assessment and reassessment to ensure needs were met.
2. Identify deficient food safety practices that had the potential to result in food borne illness. (Cross refer A749)
3. Develop a quality assurance performance improvement program that identified opportunities for improving high risk, high volume patient safety and quality of care concerns identified during the survey. (Cross refer A283)

Findings:

1. A review of the medical record for Patient 4 indicated that the patient was admitted on 7/11/18 with diagnoses that included diabetes (high levels of sugar in the blood), chronic kidney disease and severely depressed. Patient 4 was a 71 year old female with multiple medical problems according to the History and Physical Examination dated 7/12/18.

A review of the Nursing Admission Assessment, dated 7/11/18, indicated Patient 4 had a Nutritional Screen Score of 20. The instructions on the form stated, "If Nutrition Screen score is > (greater than or equal to) 20 ....call physician to order nutrition consult."

A review of a separate form titled "Nutrition Screen" dated 7/11/18, and completed by nursing staff, indicated Patient 4 had nutrition risk factors that included: BMI (body mass index) indicating obesity, major GI (gastrointestinal) surgery within the past 6 months, nausea, vomiting, diarrhea, constipation for 3 days or more, sore mouth and chewing/swallowing problems. The Risk determination score was 7 and the directions indicated that a score of "3 or more = High Nutrition Risk." The box on the form labeled "RD to follow" was checked.

A review of the "Physician Admitting Orders" dated 7/11/18 indicated the box for "Evaluate for Nutritional" was checked, indicating a Nutritional consult was ordered. A check-box adjacent to this order on the form was instructions to the nursing staff to call and leave a message for the RD to communicate a physician order for a consult. This block was left blank.

During an interview with RN 31on 8/8/18, at 3:00 P.M., she stated the box on the form that was left unchecked should have been checked indicating that the RD was informed of the consult order. RN 31 was unable to determine if the Nutritional Evaluation physician order was communicated to the RD.

During an interview with the RD on 8/8/18 at 4:00 P.M., she stated that the physician order for a Nutritional consult was not communicated via the voice mail system as required. She had reviewed the voice mail log and this consult was not on the log.

A review of Patient 4's medical record with RN 31 did not reveal a Nutrition Evaluation in the medical record. In addition, the weight record for Patient 4 showed weights recorded as follows:
7/11/18 - 182.6 pounds
7/15/18 - 183.2 pounds
7/22/18 - 177.6 pounds (5.6 pound weight loss in one week)
7/29/18 - 176.6 pounds

The medical record was reviewed with RN 31 who verified that there was no documentation that the RD or the physician were notified of weight loss. The nursing staff failed to identify a potential decline in the nutritional status even after Patient 4 was determined to be a "High Nutrition Risk" on initial assessment. There was no follow-up to ensure Patient 4 was evaluated by the RD so that intervention could be put in place to prevent a further decline in the patient's nutritional status.

During an interview with the RD on 8/8/18, at 4:15 P.M., the RD stated that she did not review patient weight records unless a nutrition consult was ordered. The RD did not have a system to evaluate the nutrition status of patients who were not referred by physician or nursing staff.

2. During the course of the survey, food safety concerns were identified which included:
a. Cooked Time and Temperature Controlled for Safety (TCS) foods were not being monitored to ensure they were cooled quickly when stored in the refrigerator to prevent to the growth of harmful microorganisms that can grow to numbers sufficient to cause food borne illness. Time and Temperature Controlled for Safety (TCS) foods include foods that can result in food borne illness if not stored at temperatures to prevent this harmful growth of disease causing organisms.

b. Patient nourishment turkey sandwiches were stored in a cupboard instead of a refrigerator in the nursing station pantry for a period of time that had the potential to result food borne illness if consumed by the patients. Multiple other items were inappropriately stored in the pantries without being covered, labeled and/or dated, or stored in the refrigerator per manufacturer's instructions.

c. One nursing station pantry refrigerator did not hold food for patients at a safe temperature or according to manufacturer's instructions. In addition, the log for the refrigerator temperatures indicated the refrigerator temperature range should be up to 46 °F (degrees Fahrenheit) when according to safe food handling, refrigerator temperatures should store TCS foods at or below 41 °F.

d. The hospital's ice machine had a significant accumulation of a brown-black gelatinous residual throughout the icemaker portion of the ice machine. The hospital did not have a system to prevent this accumulation. Additionally, manufacturer's instructions were not followed for the type of sanitizer solution used by the hospital.

e. The hospital did not maintain an air gap (at least a one-inch gap between the bottom of a drainpipe and the flood level of the drain) in multiple drains in the kitchen. When an air gap was not maintained, bacteria from the drain had the potential to enter the pipe and contaminate the equipment from which the drainpipe originated.

f. The table-mounted can opener was noted to have a significant amount of black, sticky food residual on and around the blade and on the holder for the can opener. There was no system in place to maintain the can opener in a sanitary manner.

During an interview with the Director of Food and Nutrition Services (DFANS) and the RD on 8/8/18, at 3:20 P.M., the DFANS stated that both he and the RD conducted kitchen sanitation inspections weekly. The DFANS was unable to state why the deficient practices related the unsanitary conditions were identified during the survey despite these routine inspections. The RD stated that she helped set up the form for the staff to monitor the cool down of cooked TCS foods, but did not know that one of the instructions was not accurate. The RD stated that she was covering for the hospital's regular RD who was on a leave. The covering RD was previously the DFANS and was now a per diem RD.

3. During an interview with the Director of Food and Nutrition Services (DFANS) and the RD on 8/8/18, at 3:20 P.M., the DFANS stated that both he and the RD conducted kitchen sanitation inspections weekly. The DFANS was unable to state why the deficient practices related the unsanitary conditions were identified during the survey despite these routine inspections.

The Quality Council Report - Dietary Department, 2nd Quarter (5/18 - 7/18) indicated 90 to 94 percent compliance results from the Safety and Sanitation Inspections in the department. The unsafe practice noted during the survey were not identified in these reports in order for remediation to occur.

Also during the survey, a review of Patient 4's medical record indicated the patient was identified to be at High Nutrition Risk on admission on the nursing assessment and screen. The patient did not receive a nutrition assessment by the RD despite experiencing significant weight loss during the admission.

A review of the Quality Council Report - Dietary Department, 2nd Quarter (5/18 - 7/18) for Clinical Nutrition Services indicated that the RD was collecting data on whether nutrition consults ordered as appropriate. The Dashboard Project did not indicate corrective actions plans to remediate the effectiveness of the system.

During an interview with the RD on 8/8/18, at 3:20 P.M., the RD stated that if the nursing staff or the physician did not order a consult, there was no other screening of the patients to determine if the was a need for a nutrition assessment. Therefore, Patient X did not have a nutrition assessment performed despite being identified as High Nutrition Risk and having experienced significant weight loss during the hospital stay.

During a further interview with the RD the same day, at 4:15 P.M., the RD stated that she did not review patient weight records unless a nutrition consult was ordered. The RD did not have a system to evaluate the nutrition status of patients who were not referred by physician or nursing staff. She further stated that a system to remediate this issue had not been considered.

Based on observations, interviews and record review, the hospital failed to maintain adequate food supplies to effectively implement their disaster food plan when protein-rich foods, such as peanut butter and white beans were not available in quantities to meet the needs of patient, staff and visitors. This failure had the potential to result in under nutrition of 220 patients, staff and visitors in the event of a widespread disaster.

Findings:

During a concurrent observation of the disaster food supplies, interview with the Director of Food and Nutrition Service (DFANS) and review of the hospital's "Dietary Disaster Plan" (revised 8/15) on 8/8/18, at 8:50 A.M., the hospital's disaster food supplies were reviewed. The hospital's plan required 13 cases of 100 each, 0.5-ounce peanut butter packets. The hospital had one and a half cases of the peanut butter packets. The DFANS verified that they did not have adequate peanut butter in the event of widespread disaster. He verified that the disaster food supplies should be on hand at all times in order to remain self-sufficient in case the hospital was required to shelter in place with no deliveries of food supplies. The "Disaster Menu" relied on peanut butter as a source of protein for two days of the menu.

During this same observation, interview and record review, the hospital's disaster plan required eight number 10 cans of white beans (each number 10 can contained approximately 12 cups of beans). The hospital has three number 10 cans. The DFANS verified that the white beans were on the disaster menu to add protein to a lunch entrée. The DFANS could not explain why these disaster supplies were not available or how the hospital would meet the nutritional needs of the patients, staff and visitors in the event of a widespread disaster in which deliveries of additional food supplies was not possible.,

Based on observations, interviews and record reviews, the hospital failed to develop a system for identifying and controlling potential infections resulting from unsanitary conditions in the Food and Nutrition Services department and the nursing station pantries when:

a. Cooked Time and Temperature Controlled for Safety (TCS) foods were not being monitored to ensure they were cooled quickly when stored in the refrigerator to prevent to the growth of harmful microorganisms that can grow to numbers sufficient to cause food borne illness. Time and Temperature Controlled for Safety (TCS) foods include foods that can result in food borne illness if not stored at temperatures to prevent this harmful growth of disease causing organisms.

b. Patient nourishment turkey sandwiches were stored in a cupboard instead of a refrigerator in the nursing station pantry for a period of time that had the potential to result food borne illness if consumed by the patients. Multiple other items were inappropriately stored in the pantries without being covered, labeled and/or dated, or stored in the refrigerator per manufacturer's instructions.

c. One nursing station pantry refrigerator did not hold food for patients at a safe temperature or according to manufacturer's instructions. In addition, the log for the refrigerator temperatures indicated the refrigerator temperature range should be up to 46 °F (degrees Fahrenheit) when according to safe food handling, refrigerator temperatures should store TCS foods at or below 41 °F.

d. The hospital's ice machine had a significant accumulation of a brown-black gelatinous residual throughout the icemaker portion of the ice machine. The hospital did not have a system to prevent this accumulation. Additionally, manufacturer's instructions were not followed for the type of sanitizer solution used by the hospital.

e. The hospital did not maintain an air gap (at least a one-inch gap between the bottom of a drainpipe and the flood level of the drain) in multiple drains in the kitchen. When an air gap was not maintained, bacteria from the drain had the potential to enter the pipe and contaminate the equipment from which the drainpipe originated.

f. The table-mounted can opener was noted to have a significant amount of black, sticky food residual on and around the blade and on the holder for the can opener. There was no system in place to maintain the can opener in a sanitary manner.

g. The hospital's Infection Preventionist did not develop a system for identifying and controlling potential infections resulting from these unsanitary conditions in the kitchen and nursing station pantries.

These failures to identify and control potential for food borne illness related to unsafe food handling practices and unsanitary conditions in the Food and Nutrition Services and the nursing station pantries put all 67 patients in the hospital at risk for infections.

Findings:

a. Safe cooling of cooked TCS foods requires removing heat from food quickly enough to prevent microbial (bacterial) growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic (disease causing) microorganisms. The Food Code provision for cooling provides for cooling from 135 °F to 41 °F or 45 °F in 6 hours, with cooling from 135 °F to 70 °F in 2 hours. The initial 2-hour cool is a critical element of this cooling process (Food Code, 2017).

During an observation and concurrent interview with the Director of Food and Nutrition Services (DFANS) in the kitchen, in the walk-in refrigerator, on 8/7/18, at 9:13 A.M., a pan of slice ham dated 8/8/18 was noted. The DFANS stated that the ham had been cooked, cooled and dated with a three day expiration date of 8/8/18. He further stated the cooling of the cooked ham had been recorded on the "Cooling Log".

A review of the hospital's "Daily Cooking Log for Potentially Hazardous Foods [now known as TCS foods]" dated 7/25 through 8/6/18 indicated "Ham" was cooled on 8/6/18. The ham was cooled according the Food Code requirements above. Further review, however, indicated "Quinoa", a cooked TCS food, was cooled on 8/5/18. The log indicated the Quinoa was 170 °F at 12:00 and was 36 °F at 3:30, a three and a half hour gap where no other temperature monitoring was documented. There was no documentation that the Quinoa reached 70 °F within the required 2 hour timeframe.

Further review of the "Daily Cooking Log for Potentially Hazardous Foods" indicated instructions to the staff that stated "Chill cooked, hot foods using one of these methods: ..." The first method in the instruction was consistent with the Food Code requirements. The second method, the "One-Stage" method, indicated cooked, hot foods could be cooled "Directly from 135 °F to 40 °F within a total of 4 hours. The total cooling process from 135 °F to 40 °F may not exceed 4 hours ...."

This method does not ensure the initial 2 hour cool from 135 °F to 70 °F is met which according to the Food Code is a critical element because bacteria can grow to numbers sufficient to cause food borne illness in the temperature range after more than 2 hours. Additionally, dry food such as Quinoa become a TCS food when water is added and cooked (Food Code, 2017).

During a subsequent interview with the DFANS and the Registered Dietitian (RD) on 8/8/18, at 3:20 P.M., the RD reviewed the Daily Cooling Log from the previous day and indicated that she was unaware that Quinoa even required monitoring for cool down. She further stated that she worked with the DFANS to establish the instructions to the staff on the Daily Cooling Log. She was not aware that the instructions for the "One-Stage" method of cooling cooked, hot foods was inconsistent with requirements in the Food Code. She did not know that the initial 2 hour requirement was critical. The DFANS also indicated that he did not know that the instructions to the staff on the form were not correct.

Further review of the hospital's "Daily Cooling Logs for Potentially Hazardous Foods" dating back to 1/17/18, showed that of 60 entries on the logs for cooling cooked foods, 35 entries did not document that the TCS food had been sufficiently cooled from 135 °F to 70 °F in the required 2 hours. In addition, four entries did not indicate that cooling monitoring had started when the food was at least 135 °F. The cooling log included food items such as stuffed peppers, ground beef, pork carnitas, turkey burgers, sausage links and chicken.


b. Except during preparation, cooking, or cooling ...Time and Temperature Control for Safety (TCS) food shall be maintained either at 135 °F or above or at 41 °F or less. Turkey is a TCS food. (Food Code, 2017).

During an observation in the ASU 3 nursing unit pantry on 8/7/18, at 2:45 P.M., two brown paper bags were noted in the cupboard. The bags were each labeled with a patient name and "2 P.M. snack". The bags were opened and inside each was a half of a turkey sandwich in a plastic baggie.

During a concurrent interview with the DFANS, he stated that the 2 P.M. snacks were delivered with the lunch at noon and the Behavioral Health Specialist was responsible for putting the sandwiches in the refrigerator. He stated that the sandwiches should have been placed in the refrigerator in the pantry and maintained at 41 °F until they were served to the patients. He verified that the sandwiches were not cold and appeared to have been stored in the cupboard since lunch.

During a concurrent interview with Behavioral Health Specialist (BHS 33), she stated that she was not aware that the brown bags contained sandwiches.

Also, during an observation in the ASU 2 nursing station pantry on 8/7/18, at 3:00 P.M., in the refrigerator, a half full, open container of soy milk was noted without a date or patient name. A plastic cup of a yellowish powder was not covered in the cupboard above the coffee maker. In addition, a half filled, open bottle of Gatorade was on the counter, room temperature, with no date or name on it. The manufacturer's label on the Gatorade indicated that it needed to be refrigerated after opening.

A concurrent interview was conducted with BHS 34. BHS 34 stated the soymilk should be dated and labeled with the patient's name or discarded. She was unable to state why it had not been discarded. BHS Y stated that the yellow powder was a protein powder and it should be covered and labeled. She also did not know why the Gatorade was on the counter without a date or label.

During a concurrent interview with the DFANS, he verified that the Gatorade label indicated that it should be refrigerated after opening and the bottle was found on the counter at room temperature.

c. Except during preparation, cooking, or cooling ...Time and Temperature Control for Safety (TCS) food shall be maintained either at 135 °F or above or at 41 °F or less. Milk and yogurt are TCS foods. (Food Code, 2017).

During an observation in the ASU 3 nursing station pantry on 8/7/18, at 2:50 P.M., the thermometer used to monitor the refrigerator temperature registered 50 °F. The refrigerator contents included milks and yogurts used as snacks for the patients. The temperature of the milk was tested with a thermometer that register 50 °F. The yogurt registered 48.7 °F.

During a concurrent interview with the DFANS, he stated that it was the responsibility of the nursing staff to monitor the temperature of the pantry refrigerators on the Daily Nutrition Refrigerator/Freezer Temperature Log every morning.

A review of the "Daily Nutrition Refrigerator/Freezer Temperature Log" in the ASU 3 pantry dated August 2018 indicated that the temperature recorded for 8/7/18 was 46 °F, too high to maintain the TCS foods at 41 °F or less for safety. Upon further review, the instructions on the log stated, "Refrigerator temperature is to be maintained between 36 degrees and 46 degrees Fahrenheit ...."

During a concurrent interview with the DFANS, he could not explain why the safe temperature parameters on the form indicated that a range of 36 to 46 °F was acceptable. He verified that according to the form, the recorded temperature for that day was within the acceptable range and there was no action required. He verified the temperatures taken of the milk and yogurt and stated that they had not been stored at the safe temperature.

Also noted in the refrigerator during the same observation was a bowl that contained six "Uncrustable" peanut butter and jelly sandwiches. The manufacturer's package instructions on the sandwiches stated 'Keep Frozen, thaw for 30 to 60 minutes, eat within 8 to 10 hours." The bowl was labeled with an expiration date of 8/12/18, five days later. The sandwiches were not labeled with a date or time they were thawed. The DFANS was not aware of the manufacturer's instructions regarding the thawed shelf life of the sandwiches. He verified that the sandwiches should not be stored in the refrigerator unless they were monitored to be sure they were either consumed or discarded within 8 to 10 hours per manufacturer's instructions.

d. During an observation of the hospital's only ice machine in the kitchen on 8/7/18, at 9:50 A.M., a clean white napkin swipe of the bottom of the water trough in the icemaker produced a significant amount of a brown/black gelatinous residue. Also observed was a brown residue throughout the icemaker including the curtain, inside the water trough and on the rubber tubing. The DFANS and Maintenance Staff 1 verified these observations.

During a concurrent interview with the DFANS and MS 1, MS 1 stated that the ice machine was last cleaned on May 30, 2018. He stated that the maintenance staff cleaned and serviced the icemaker portion of the ice machine. MS 1 could not explain why there was a significant buildup of the observed residue in and around the icemaker. He further stated that the icemaker was scheduled to be cleaned next at the end of August, in 3 weeks. MS 1 indicated that the residue observed was pretty bad. The DFANS stated that the nutrition services staff cleaned the ice storage bin portion of the ice machine monthly. He stated that when the nutrition service staff cleaned the bin, they were unable to reach the top of the storage bin, where the icemaker was located. He further stated that it was his expectation that the maintenance staff was cleaning it. The DFANS indicated that the residue observed throughout the icemaker was significant.

During an interview with Maintenance Staff 2 (MS 2) the same day at 10:10 A.M., he stated that he was responsible for cleaning the icemaker. MS 2 stated that he did not wipe down the parts of the icemaker that were noted to have the residue build up. He further stated that after he cleaned the icemaker, he used a quaternary ammonia sanitizer to sanitize the ice machine.

During a concurrent interview with the Director of Plant Operations (DPO), he stated that his staff cleans the ice machine to maintain function, not for cleanliness.

A review of the hospital's "Ice Machine Cleaning/Maintenance Schedule" dated 2018, indicated the last maintenance was performed on 5/30/18 and the next scheduled maintenance was in August but had not been completed yet.

According to the ice machine manufacturer's instructions on cleaning and sanitizing the ice machine, "If necessary, wipe the evaporator, spillway and other water transport surfaces with a soft clean cloth to remove any remaining residue. If necessary, remove the water distribution tube, disassemble and clean with a bottlebrush ....Turn off the machine water supply and clean the water trough thoroughly to remove all scale or slime build-up."

During the interview with MS 2 on 8/7/18, at 10:10 A.M., he stated that he did not do these steps according to the manufacturer's instructions.

Also according to the ice machine manufacturer's instructions, the solution that was supposed to be used for sanitizing the ice machine was food safe bleach solution not a quaternary ammonia solution as MS 2 had indicated that he used.

e. An air gap is the space between the end of a kitchen equipment drainpipe and the flood level of the drain sink. This space is required to be at least one inch or twice the diameter of the opening of the drainpipe. The purpose of an air gap is to prevent the backflow of sewage water from contaminating the drainpipe and the kitchen equipment with disease causing microorganisms (Food Code, 2017).

During an observation in the kitchen on 8/7/18, at 10:20 A.M., the end of the drainpipe from the ice machine's ice storage bin was noted in the floor drain sink. Also observed, the drainpipes from the warewashing sinks and the food preparation sinks were not maintaining an air gap.

During a concurrent interview with the Director of Plant Operations (DPO), he stated that there should be an air gap maintained at all three of these equipment drainpipes. He stated that the pipes may have been knocked out of place during cleaning.

During a concurrent interview with the DFANS, he was not aware that an air gap was required. He verified that there was no system for identifying and resolving issues with the air gaps.

f. During an observation in the kitchen on 8/7/18, at 9:36 A.M., the table mounted can opener was noted to contain a significant amount of a black sticky residue around the blade, the gears of the can opener and all around the base that holds the can opener. In addition, the blade was worn and nicked so that it was no longer a smooth surface.

During a concurrent interview with the Director of Food and Nutrition Service (DFANS), he stated that the can opener was cleaned weekly. He also stated that the blade was not changed on a regular basis but as needed. He could not explain why the can opener was not clean. He further could not explain how the dirty can opener could prevent cross contamination that could result in food borne illness when opening cans of food for the patients and staff.

According to the 2017 Food Code, equipment food-contact surfaces and utensils shall be clean to sight and touch. Additionally, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Moreover, cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened.

g. During a telephone interview with the hospital's Infection Preventionist (IP) on 8/9/18, at 2:30 P.M., the IP stated that she had not identified, as problematic, any of the issues that were observed during the survey. She had not identified problems with air gaps, cool down procedures, the ice machine cleanliness, refrigerator logs in the nursing station pantries, or food being stored safely in the pantries.

This Condition is not met as evidenced by:

Based on record review and interview the facility failed to:

I. Ensure Psychiatric Evaluations included an assessment/estimation of memory and/or intellectual functioning for five (5) of eight (8) patients (Patients A1, A2, A3, A5 and A8) and patient's assets for sic (6) of eight (8) active sample patients (Patients A1, A2, A4, A5, A6 and A8) in descriptive not interpretive terms. (Refer to B116 and B117)

II. Ensure that the Master Treatment Plans (MTPs) were comprehensive and individualized, including appropriate Short and Long Term goals and treatment Interventions, to address patients' identified problems for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). (Refer to B118, B121 and B122)

III. Ensure that appropriate and adequate active treatment/activities were offered to one (1) of eight (8) patients (Patient A3) to meet the patient's needs including alternative treatment interventions for a patient unable or unwilling to attend offered groups. (Refer to B125)

IV. Ensure that all members of the treatment team document in their treatment/progress notes, for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8) that referred to assigned interventions, and that would describe whether a patient was making progress towards expected goal achievement or not, and modify treatment plans as needed. (Refer to B132)

Based on document review and staff interview, the facility failed to ensure that the Psychosocial Assessments for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8) included anticipated Social Work roles in treatment, including treatment interventions for identified high risk concerns and discharge planning. Also, for five (5) of eight (8) patients (Patients A1, A2, A4, A6 and A7) the Psychosocial Assessments were completed by non MSW qualified staff and there was no documented evidence that these staff were supervised by a MSW qualified staff member. As a result, critical and professional patient psychosocial information necessary for informed treatment planning decisions was not available to the treatment teams.

Findings include:

A. Record Review

1. Patient A1 was admitted for "Alcohol and triple C" on 7/26/18. The Psychosocial Assessment completed on 7/27/18 did not identify anticipated roles for social work staff in formulating interventions for identified high risk concerns of "Chemical dependency with reported history of PTSD", and discharge planning. The staff member's qualification who completed this assessment was "MFT" [Marriage and Family Therapist] and there was no documented evidence a MSW qualified staff supervised this Assessment.

2. Patient A2 was admitted for "I am an alcoholic" on 7/18/18. The Psychosocial Assessment completed on 7/20/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment and discharge planning. The staff member's qualification who completed this Assessment was "MFT" and there was no documented evidence a MSW qualified staff supervised this Assessment.

3. Patient A3 was admitted for "I need new meds." on 6/22/18. The Psychosocial Assessment completed on 6/23/18 did not identify any anticipated roles for social work staff in formulating interventions for inpatient treatment including addressing identified high risk issues "SI." (suicidal ideation).

4. Patient A4 was admitted for "Pt. denied - Unable to assess" on 7/4/18. The Psychosocial Assessment completed on 4/8/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including "High Risk issue"- "Pt. stopped taking meds." The staff members qualification who completed this assessment was "MFT" and there was no documented evidence a MSW qualified staff supervised this assessment.

5. Patient A5 was admitted for "Depression and chronic pain" on 5/23/18. The Psychosocial Assessment completed on 5/24/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including "High Risk issues to be Addressed." "Depressed mood." and discharge planning.

6. Patient A6 was admitted for "I have a drinking problem." on 7/26/18. The Psychosocial Assessment completed on 7/30/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment and discharge planning. This assessment was completed by a staff member with "MFT" qualification and there was no documented evidence that a staff with MSW qualification supervised.

7. Patient A7 was admitted for "I went to sleep in the pool and sank down, and scotty barked and saved me." on 7/11/18. The Psychosocial Assessment completed on 7/12/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment and discharge planning. The staff member's qualification who completed this Assessment was "MFT" and there was no documented evidence a MSW qualified staff supervised this assessment.

8. Patient A8 was admitted for "I was having suicidal thoughts" on 7/23/18. The Psychosocial Assessment completed on 7/24/18 did not identify anticipated roles for social work staff in formulating interventions for inpatient treatment including the identified high risk issues "SI." and discharge planning.

B. Policy Review:

Hospital policy #: 200.81.01, Subject: Psychosocial Evaluations, last reviewed on 8/12/07, under "Purpose" states "3. To identify psychosocial needs, thereby facilitating the development of appropriate treatment plan interventions and discharge plans."

C. Staff interview:

In a meeting and review of the above deficiencies in the Psychosocial Assessments with the Director of Clinical Services and the Lead Social Work staff on 8/9/18 at 10:00 a.m., they did not dispute the above deficiencies and stated " ...agree do not meet the standards, we have work to do."

Based on document review and interview, the facility failed to assess and estimate memory and/or intellectual functioning in a descriptive manner to establish baseline parameters for five (5) of eight (8) active sample patients (Patients A1, A2, A3, A5 and A8). This failure makes it impossible to establish objective baseline functioning for future comparisons and follow changes to adjust treatments as appropriate.

Findings include:

A. Record Review

1. Patient A1: Psychiatric Evaluation dated 7/30/18 had no assessment and documentation of intellectual functioning, and memory assessment was documented as "intact" without any evidence of how this was assessed.

2. Patient A2: Psychiatric Evaluation dated 7/23/18 had no assessment and documentation of intellectual functioning, and memory assessment was documented as "intact" without any evidence of how this was assessed.

3. Patient A3: Psychiatric Evaluation dated 6/23/18 had documentation of intellectual functioning assessment as "average, by historical" and memory assessment was "unable to assess".

4. Patient A5: Psychiatric Evaluation dated 5/25/18 had no assessment and/or documentation of intellectual functioning, and memory assessment was documented as "intact" without any evidence of how this was assessed.

5. Patient A8: Psychiatric Evaluation dated 7/26/18 had documentation of intellectual functioning as "average" and memory was documented as "not impaired" without any evidence of how this was assessed.

B. Document Review:

The "4.6 Admission Documentation" of the Rules and Regulations of the medical staff Bylaws states "A psychiatric evaluation including an initial treatment plan of treatment, mental status examination, diagnosis and estimated length of stay, shall be completed and documented within 24 hours after admission of the patient." and does not list the details or contents of these evaluations.

C. Staff Interview:

In a meeting and review of these deficiencies on 8/9/18 at 9:00 a.m., the medical director did not dispute the above deficiencies.

Based on record review and staff interview, the facility failed to provide Psychiatric Evaluations that included an assessment of patient's assets in descriptive and not interpretive terms for 6 of 8 active sample patients (Patients A1, A2, A4, A5, A6 and A8). This failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's personal attributes in formulating treatment interventions.

Findings include:

A. Record Review:

1. Patient A1's Psychiatric Evaluation dated 7/30/18 had "polite and cooperative" as patient's strength, which is not a patient's personal asset that can be utilized in treatment planning during current hospitalization.

2. Patient A2's Psychiatric Evaluation dated 7/23/18 had "polite, cooperative" as patient's strength.

3. Patient A4's Psychiatric Evaluation dated 7/15/18 had "Limited family support" as patient's strength, which is not a patient's personal asset that can be utilized in treatment.

4. Patient A5's Psychiatric Evaluation dated 5/25/18 had "polite and cooperative and has a supportive family." as patient's strengths.

5. Patient A6's Psychiatric Evaluation dated 7/27/18 had "As specified on psychiatric evaluation." as patient's strength.

6. Patient A8's Psychiatric Evaluation dated 7/26/18 had "Motivated. [she/he] has parental support.", which is not a personal attribute that can be utilized in current treatment planning.

B. Staff Interview:

A sample of these deficiencies were reviewed with the Medical Director on 8/9/18 at 9:00 a.m. as He agreed with the above findings and further stated "Things are not perfect".

Based on medical record review, staff interview and policy review the facility failed to ensure that for 1of 8 patients (Patient A6) there was an individual comprehensive treatment plan. Failure to develop an individualized Master Treatment Plan hinders the staff's ability to provide coordinated care for the patient, potentially resulting in the patient's treatment needs not being met. Specifically, the facility did not develop and document a treatment plan for the patient that included, a description of the problems identified, strengths, goals and interventions.

Findings include:

I. Record Review:

Patient A6:

The patient was admitted 7/26/18 with a diagnosis of alcohol and cocaine abuse and a treatment plan dated 7/27/18. This document included a diagnosis of alcohol and cocaine abuse with problems listed as depressed mood, anxiety and substance abuse. There were no identified strengths, description of the problems to be addressed, long term and short-term goals or staff interventions. The treatment team and the patient signed off on the treatment plan even though there were none of the components listed above.

II: Staff Interview:

On 8/8/18 at 1:15 p.m. RN3 and BHW1 could not find any additional components of the treatment plan in the medical record indicating strengths, description of the problems, long term and short-term goals and interventions.

On 8/8/18 at 3:30 p.m. the DON acknowledged that after several requests for the treatment plan, the entire treatment plan was not recorded in the medical record.

Epiploic Review:

Section/Page 600.08.01 with a review date of 8/12 titled: Subject: Interdisciplinary Treatment Plan.

Policy

"Each patient admitted to the hospital shall have a written, individualized treatment plan. Based on assessments of clinical needs, the plan shall describe patient strengths and disabilities: goals and objectives of treatment: clinical interventions prescribed: ... ... ... ...In essence, the treatment plan serves as an organizational tool whereby the care rendered each patient is designed. implemented, assessed, and updated in an orderly and clinically sound manner."

Based on medical record review, staff interview and policy review the facility failed to include on the Master Treatment Plan (MTP) an inventory of the patient's strengths (assets) that represent personal assets in six (6) of eight (8) active sample patients (Patients A1, A2, A3, A4, A6 and A8). This failure impairs the treatment team's ability to utilize the patient's attributes in determining the interventions to be established to meet the patient's goals.

Findings include:

I. Record Review:

1. Patient A1 admitted 7/26/18 with a MTP dated 7/26/18 did not have any assets listed.

2. Patient A2 admitted 7/18/18 with a MTP dated 7/18/18 listed "Supportive Family/Friends and Motivation for Treatment/Growth" as assets.

3. Patient A3 admitted 6/22/18 with a MTP dated 6/22/18 listed "General Fund of Knowledge and Supportive Friend" as assets.

4. Patient A 4 admitted 7/4/18 with a MTP dated 7/4/18 listed "Supportive Family/Friends and Physical Health" as assets.

5. Patient A 6 admitted 7/26/18 with a MTP dated 7/27/18 (incomplete plan) did not have any assets listed.

6. Patient A8 admitted 7/23/18 with a MTP dated 7/23/18 listed "General Fund of Knowledge" as assets.

II. Staff Interview:

In a meeting with the facility's Director of Nursing and the Director of Clinical Programming on 8/7/18 at 3:30 p.m., it was acknowledged that the strengths identified are not specific to the patient's personal assets.

III. Policy Review:

Section/Page 600.08.01 with a review date of 8/12 titled: Subject: Interdisciplinary Treatment Plan under Treatment Plan Components:

"2. Strengths/Liabilities: Listing of strengths and liabilities that may be utilized in development of treatment plan interventions."

Based on medical record review, staff interview and policy review the facility failed to identify a diagnosis that served as the primary focus for the Treatment Plan for 1 of 8 active sample patients (Patient A1). Failure to include the diagnosis hinders the primary focus upon which the Treatment Plan is based and compromises the staff's ability to deliver clinically focused treatment.

Findings include:

I. Record Review:

Patient A1 admitted 7/26/18 with a MTP dated 7/26/18, did not have a diagnosis listed on the MTP.

II. Staff Interview:

In an interview with the Director of Nursing and the Director of Clinical Programming on 8/7/18 at 3:30 p.m. it was acknowledged that there was no diagnosis on the Treatment Plan.

III. Policy Review:

Section/Page 600.08.01 with a review date of 8/12 titled: Subject: Interdisciplinary Treatment Plan under Treatment Plan Components:

"1. Diagnosis: At the time of the Treatment Planning meeting, all five axes will be recorded as determined by the physician."

Based on medical record review and staff interview the facility failed to specify short term goals in observable, measurable patient behaviors to be achieved in eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, A5, A6, A7and A8). Several of the identified goals were generic staff expectations and did not address patient specific presenting problems or were not written in observable, behavioral and measurable terms. In addition, the goals identified for the individual patient's problems were the same goals identified on each patient's treatment plan when that particular problem was identified. This lack of individualization of short term goals make it difficult to judge the effectiveness of the treatment goals for each individual patient. Lack of individualization with treatment goals for a specific problem limits the effectiveness of treatment and the ability to implement possible changes in treatment. These failures can hamper how clinical staff evaluate each patient and make necessary changes in the goals for the patient to accomplish.

The findings include:

I. Record Review:

A. Problem: Substance Abuse

1. Patient A1 admitted on 7/26/18 with a diagnosis of Alcohol Use Disorder, Moderate and Other Substance Use Disorder, Moderate; with MTP dated 7/26/18 the short term goals were as follows:

a. Patient will communicate symptoms or needs to hospital staff during detox.

b. Patient will verbalize adaptive ways to deal with stressors to remain clean and sober.

c. Patient will state that addictions is a problem in his/her life.

d. Patient will describe plans for a recreation activity that does not involve drug or alcohol.

e. Patient will verbalize understanding of disease concept.

f. Patient will involve family in education and relapse prevention activities.

g. Patient will attend AA/NA meeting and obtain a sponsor.

h. Patient will identify plans to address pending legal issues.


2. Patient A2 admitted on 7/18/18 with a diagnosis of Alcohol Use Disorder Severe, with MTP dated 7/18/18 with short term goals as follows:

a. Patient will communicate symptoms or needs to hospital staff during detox.

b. Patient will verbalize adaptive ways to deal with stressors to remain clean and sober.

c. Patient will state that addictions is a problem in his/her life.

d. Patient will describe plans for a recreation activity that does not involve drug or alcohol.

e. Patient will verbalize understanding of disease concept.

f. Patient will involve family in education and relapse prevention activities.

g. Patient will attend AA/NA meeting and obtain a sponsor.

h. Patient will identify plans to address pending legal issues.

3. Patient A6 was admitted on 7/26/18 with a diagnosis of Alcohol and Cocaine Disorder Continuous and Severe with an MTP dated 7/27/18. The patient has an incomplete treatment plan which lacked short term goals.

B. Problem: Depressed Mood

1. Patient A3 was admitted 6/22/18 with a diagnosis of Schizoaffective Depressed Type with an MTP dated 6/22/18 with short term goals as follows:

a. Patient will demonstrate brighter mood and affect.

b. Patient will sleep 8 hrs./night for 3 consecutive nights.

c. Patient will eat 75% of meals within 7 days.

d. Patient will demonstrate simple decision making regarding daily structure.

e. Patient will verbalize absence of active SI/HI

f. Patient will participate actively and appropriately in groups as indicated by expressing thoughts and feelings appropriately.

g. Patient will demonstrate an increase in self-esteem through attention to personal hygiene and grooming.

2. Patient A 5 admitted on 5/23/18 with a diagnosis of Major Depression Disorder, Recurrent, Severe with an MTP dated 5/23/18 with short term goals as follows:

a. Patient will demonstrate brighter mood and affect.

b. Patient will sleep 7 hrs./night for 3 consecutive nights.

c. Patient will eat 75% of meals within 7 days.

d. Patient will demonstrate simple decision making regarding daily structure.

e. Patient will verbalize absence of active SI/HI

f. Patient will participate actively and appropriately in groups as indicated by expressing thoughts and feelings appropriately.

g. Patient will demonstrate an increase in self-esteem through attention to personal hygiene and grooming.

3. Patient A 7 admitted on 7/11/18 with a diagnosis of Bipolar Mood Disorder, Recurrent, Severe, with psychosis, type 1 with short term goals as follows:

a. Patient will demonstrate brighter mood and affect.

b. Patient will sleep 7 hrs./night for 3 consecutive nights.

c. Patient will eat 70% of meals within 7 days.

d. Patient will demonstrate simple decision making regarding daily structure.

e. Patient will verbalize absence of active SI/HI

f. Patient will participate actively and appropriately in groups as indicated by expressing thoughts and feelings appropriately.

g. Patient will demonstrate an increase in self-esteem through attention to personal hygiene and grooming.

4. Patient A8 admitted on 7/23/18 with a diagnosis of Major Depressive Disorder Severe and OCD with short term goals as follows:

a. Patient will demonstrate brighter mood and affect.

b. Patient will sleep____ hrs./night for 3 consecutive nights.

c. Patient will eat____ of meals within 7 days.

d. Patient will demonstrate simple decision making regarding daily structure.

e. Patient will verbalize absence of active SI/HI

f. Patient will participate actively and appropriately in groups as indicated by expressing thoughts and feelings appropriately.

g. Patient will demonstrate an increase in self-esteem through attention to personal hygiene and grooming.

C. Problem: Self-Harm

1. Patient A 3 admitted with a diagnosis Schizoaffective Depressed Type with short-term goals as follows:

a. Patient will not harm self while in hospital.

b. Patient will identify triggers to self-harm feeling and behaviors.

c. Patient will seek staff out when feeling urge to harm self.

d. Patient will report decrease in suicidal ideation.

e. Patient will participate in development of aftercare plan with focus on addressing suicidal or self-harm feelings.

f. Patient will verbalize understanding of how substance abuse relates to mood and suicidal thoughts and behavior.

g. Patient will identify at least one support system to assist with thoughts of Suicide or Self-harm post discharge.

2. Patient A4 admitted on 7/4/18 with diagnosis of Schizoaffective disorder, bipolar type with MTP dated 7/5/18 with STGs as follows:

a. Patient will not harm self while in hospital.

b. Patient will identify triggers to self-harm feeling and behaviors.

c. Patient will seek staff out when feeling urge to harm self.

d. Patient will report decrease in suicidal ideation.

e. Patient will participate in development of aftercare plan with focus on addressing suicidal or self-harm feelings.

f. Patient will verbalize understanding of how substance abuse relates to mood and suicidal thoughts and behavior.

g. Patient will identify at least one support system to assist with thoughts of Suicide or Self-harm post discharge.

3. Patient A 5 admitted on 5/23/18 with a diagnosis of Major Depressive Disorder, Severe, Recurrent with MTP dated 5/23/18 with short term goals as follows:

a. Patient will not harm self while in hospital.

b. Patient will identify triggers to self-harm feeling and behaviors.

c. Patient will seek staff out when feeling urge to harm self.

d. Patient will report decrease in suicidal ideation.

e. Patient will participate in development of aftercare plan with focus on addressing suicidal or self-harm feelings.

f. Patient will verbalize understanding of how substance abuse relates to mood and suicidal thoughts and behavior.

g. Patient will identify at least one support system to assist with thoughts of Suicide or Self-harm post discharge.

4. Patient A8 admitted on 7/23/18 with a diagnosis of Major Depressive Disorder Severe and OCD with short goals as follows:

a. Patient will not harm self while in hospital.

b. Patient will identify triggers to self-harm feeling and behaviors.

c. Patient will seek staff out when feeling urge to harm self.

d. Patient will report decrease in suicidal ideation.

e. Patient will participate in development of aftercare plan with focus on addressing suicidal or self-harm feelings.

f. Patient will verbalize understanding of how substance abuse relates to mood and suicidal thoughts and behavior.

g. Patient will identify at least one support system to assist with thoughts of Suicide or Self-harm post discharge.

II. Staff Interview:

In an interview with the Director of Nursing and the Director of Clinical Programming on 8/7/18 at 3:30p.m. the Director of Nursing stated "The problems, diagnosis and the goals do not match".

Based on record review, staff interview, and policy review the facility failed to develop a Master Treatment Plan (MTP) that had interventions with specific focus based on the individual needs of the patient for eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). The interventions on the plans included routine clinical functions that were required of all patients regardless of their assessment of needs and the short-term goals identified. In addition, the interventions in many instances were the same interventions for all patients who had the same specific problem identified. The interventions were listed consecutively, and it could not be determined which interventions related to which short term goals. This deficiency resulted in a failure to provide a basis for goal-directed treatment and to plan for revisions based on the individual's progress or lack of progress.

The findings include:

I. Record Review:

1. Patient A1 admitted on 7/26/18 with a diagnosis of Alcohol Use Disorder, Moderate with a MTP dated 7/26/18 did not have physician interventions for problems of PTSD and Substance Abuse.

Nursing interventions were routine nursing functions for both problems listed on treatment plan: "Nursing to assess suicidality, mood, affect for PTSD; Nursing will monitor VS & physical symptoms to assess patient's detox status and need for medications; Nursing to administer detox medications per orders and document patient response; Nursing to monitor medications effectiveness".

2. Patient A2 admitted on7/18/18 with a diagnosis of Alcohol Disorder, Severe with a MTP dated 7/18/18 did not have physician interventions for substance abuse problem.

Nursing interventions were routine nursing functions for the substance abuse problem; "Nursing to monitor VS & physical symptoms to assess patient's detox status and need for medications; Nursing to administer detox medications per orders and document patient response; Nursing to monitor medications effectiveness".

3. Patient A3 admitted on 6/22/18 with a diagnosis of Schizoaffective Disorder, and a medical diagnosis of diabetes mellitus type2. There were no physician interventions for the problems of depressed mood, self- harm and diabetes.

Nursing interventions were routine nursing functions: "RN to assess suicidality, mood, affect; RN to assess mood, behavior, affect and suicidal ideation q shift while patient awake; RN to assess patient response to and perception of effectiveness of medication". For the problem of diabetes, interventions listed were "Adequate hydration/proper hygiene, good hand washing, disposal of tissues, monitor blood sugar and DM diet; provide medication education including side effects".

4. Patient A4 admitted on 7/4/18 with a diagnosis of Schizoaffective Bipolar Type with a MTP dated 7/4/18 with problems of impaired thought process, and self-harm.

Nursing interventions were routine nursing functions: "RN to assess mental status, current hallucinations, delusions and orientation; RN to assess patient response to and perception of effectiveness of medication; Monitor & document ability to complete ADLS; RN to assess mood, behavior, and suicidal ideation q shift while patient awake."

5. Patient A5 admitted on 5/23/18 with a diagnosis of Major Depression Disorder Recurrent, Severe and Chronic Back Pain with an MTP dated 5/23/18. There were no physician interventions for the problems of depressed mood, self-harm, anxiety, and chronic pain.

Nursing interventions were routine nursing functions to assess suicidality, mood, affect; "RN to assess patient response to and perception of effectiveness of medications; Administer medication Percocet ordered to treat current symptoms of ____________________; RN to assess patient level of response to all pain management techniques used by the patient; Encourage patient to seek out staff when symptoms occur".

6. Patient A6 admitted on 7/26/18 with a diagnosis of Alcohol and Cocaine Use Disorder severe. The treatment plan dated 7/27/18 was incomplete and lacked interventions.

7. Patient A7 admitted on 7/11/18 with a diagnosis of Bipolar Mood Disorder, Recurrent Severe, with Psychosis, Type 1 and Diabetes Mellitus had a MTP dated 7/11/18 with problems listed as "Self-harm, Anxiety, Diabetes Mellitus, Manic, Depressed Mood, and Fall Risk."

Nursing Interventions were routine nursing functions:" Assess patient's condition and response to treatment via results of finger stick checks results and patient's presentation; Monitor blood sugar via accu-checks every day; RN to assess patient response to and perception of effectiveness of medications to promote stabile mood and return to baseline function; RN to assess suicidality, mood, affect".

8. Patient A 8 admitted with a diagnosis of Major Depressive Disorder, Severe and OCD with problems listed as Depressed Mood and Self-Harm. On the MTP dated 7/23/18 there were no physician interventions for the problems of depressed mood and self-harm.

Nursing interventions were routine nursing functions to assess suicidality, mood, affect; "RN to assess patient response to and perception of effectiveness of medications; RN to assess mood, behavior, affect and suicidal ideation q shift while patient awake".

II. Staff Interview

1. On 8/7/18 at 10:15 a.m. RN 3 acknowledged that the interventions needed to relate to the goals.

2. In a meeting and review with Director of Nursing and Director of Clinical Programming on 8/8/18 at 3:30 p.m., they did not dispute the above findings.

III. Policy Review

Section/Page: 600.08.01 Subject: Interdisciplinary Treatment Plan: Treatment Plan Components:

1. Interventions: Interventions for each appropriate discipline will be included for each problem. The interventions include the following components.

a. Action: Specific interventions (group therapy, administration of antidepressant, activities therapy, psych testing ,1:1, suicidal precautions etc.)

c. Focus: The specific focus of the intervention as related to the problem. (i.e., "to assist the patient in developing skills in dealing with conflict")

Based on medical record review, staff interview and policy review the facility failed to ensure that the name and discipline of staff persons responsible for specific aspects of care were listed on the Master Treatment Plans for six 6) of eight (8) active sample patients (Patients A1, A2, A3, A5, A6 and A8) This practice resulted in the facility's inability to monitor staff accountability for specific modalities.

Findings include:

I. Record Review

1.Patient A1 for problems PTSD and Substance Abuse there was no name listed for the attending physician.

2. Patient A2 for problem Substance Abuse there was no name listed for the attending physician.

3. Patient A3 for problems Self-Harm, Depressed Mood, Diabetes there was no name listed for the attending physician.

4. Patient A5 for problems Depressed Mood, Self-Harm, Anxiety, Chronic pain there was no name listed for the attending physician.

5. Patient A6 did not have a completed treatment plan.

6. Patient A8 for the problems Depressed Mood, Self Harm there were no name listed for the attending physician.

II. Staff Interview

A sample of these MTPs were reviewed in a meeting with the medical director on 8/9/18 at 9 a.m. and he did not dispute the findings.

III. Policy Review

Section/page: 600.08.01 Subject: Interdisciplinary Treatment Plan: Treatment Plan Components:

7. Interventions: Responsible Staff: The name(s) and credentials /discipline of the specific staff members responsible for the provision of the intervention.

Based on record review, observation and staff interview, the facility failed to provide active treatment, including alternative interventions for 1 of 8 active sample patient (Patient A3). This patient was either not emotionally stable to participate in group treatments or was not motivated to attend groups that s/he was expected to attend as listed on the patient's treatment plan. According to unit staff, this patient spent many hours isolated in his/her room without any structured activities. As the facility failed to provide alternative treatment interventions this non-participation negated the clinical effectiveness of the patients' treatment goals and objectives; potentially delaying the patient's improvement.

Findings include:

A. Record review

a. Patient A3 was admitted on 6/22/18. According to the Psychiatric Evaluation dated 6/23/18, the patient's admitting diagnosis was "Schizoaffective disorder, bipolar type, ? Autism ? borderline vs antisocial personality disorder. "

b. The Master Treatment Plan (MTP) was initiated on 6/26/18 and listed "Self Harm" and "Depressed mood" as the 2 Psychiatric problems to be addressed. This MTP was reviewed and updated weekly and the last update was on 7/31/18. For the problem of self harm, the STG was "patient will not harm self while in the hospital, will identify triggers to self-harm feelings and behaviors. Will seek staff out when feeling urge to harm self. Will report decrease in suicidal ideation. Will participate in development of aftercare plan with focus on addressing suicidal or self harm feelings." Listed interventions included, Nursing: "Goals and wrap-up groups assist patient in setting productive goals." Psychiatrist: No interventions listed. Social services: "Psychoeducation groups- daily, Process groups- daily." Activity Therapy: "Activity Therapy groups to provide patient skills in peer support, improve self- expression and relaxation techniques." For the problem of Depressed mood, the patient was expected to attend the same groups listed for self-harm daily by the social services staff and the activity therapy staff.

A review of the Weekly Treatment Plan Updates indicated no modifications to the treatment plan/goals and interventions and only [check off on pre printed forms] noted A: Progress as expected or E: problem resolved.

c. Staff was asked to provide a copy of all individual /group treatment notes for this patient from all disciplines for the week of 8/1/18 to 8/7/18. A review of the group attendance notes indicated this patient did not attend 12 of the 14 groups offered and for the remaining 2 groups, the patient "left after a few minutes.", and his/her participation was noted as "intrusive", "poor boundaries with peers" and "difficult to redirect" and "minimal ability to focus". Only the 8/2/18 group notes indicates "was offered handouts but declined." The Nursing/BHS's [Behavioral Health Staff] daily progress notes for this same period indicated that daily, "patient refused groups" and/or "did not attend any groups today."

d. The facility "Interdisciplinary Treatment Plan" policy last reviewed on 8/12 states "reviews and updates shall include" "B. Modifications or additions made to goals and interventions, as appropriate." The policy on "Group Progress Notes ", last reviewed on 4/14 states "4.0 In the event that a patient doesn't attend group, a note should be completed to record their absence."

B. Observation

On 8/7/18 at 3:45 p.m. patient A3 was found in bed. When interviewed with RN I Patient A3 was asked about attending groups, the patient stated, " I don't like them." On 8/8/18 at 2 p.m., again Patient A3 was in bed and was not participating in the on unit "DBT group "and this observation was confirmed by RN I. Also, at 10:40 a.m. on 8/9/18 again Patient A3was standing in the hallway not participating in the on unit "Nutrition group" which was confirmed by RN4. When RN1 was asked about the Patient A3's non- attendance and what alternative interventions had occurred RN 1 stated "been in seclusion restraints a lot" and that "they get a print out if they don't go to groups."

C. Interviews

In a meeting with the Director of Nursing and corporate Director of Clinical programming on 8/8/18 at 3:15 p.m., patients' MTPs and lack of attendance in group therapy and lack of alternative interventions was reviewed. They agreed with the findings and stated, "The treatment plans are not individualized" and that they are in the process of revising the treatment plan policy and procedures.

Based on record review, staff interview and policy review the facility failed to ensure that nursing and social service progress notes adequately documented progress towards the patient's achieving their treatment goals in eight (8) of eight (8) active sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). This failure resulted in the treatment team's inability to assess or evaluate the patient's response to treatment. The findings include:

I. Record Review:

Nursing Progress and Behavioral Health Staff Notes were essentially check off sheets on all three shifts and did not relate to the patient's problems and treatment goals. A week of progress notes from all disciplines August 1 through August 7, 2018 were reviewed to determine their relationship to the goals and interventions.

Social Work Progress notes were absent in the record for all eight (8) active sample patients. (Patients A1, A2, A3, A4, A5, A6, A7 and A8) There were approximately 15 groups led by social service on a weekly basis. Discharge planning notes that addressed discharge criteria were absent in all eight (8) active sample records

1. Patient A 1 MTP dated 7/26/18 contained the treatment intervention process group by social service to "provide patient opportunity to express & work through concerns r/t problems caused by substance abuse." There were no group process notes for this patient nor were there any discharge planning notes that addressed discharge criteria.

2. Patient A2 MTP dated 7/18/18 contained the treatment intervention process group by social service to "provide patient opportunity to express & work through concerns/ problems caused by substance abuse". There were no group notes nor were there any discharge planning notes that addressed discharge criteria.

3. Patient A3 MTP dated 6/22/18 treatment intervention listed Psychoeducation education groups on": Cognitive and Behavioral Therapy to assist in identifying coping skills, support system and illness relapse program". Patient attended Cognitive therapy group on 8/1/18 and attended cognitive therapy group for a few minutes on 8/3/18.There was no documentation as to whether the social worker reviewed the group goals with the patient on an individual basis or gave patient material related to group goals. There were no discharge planning notes that addressed discharge planning.

4. Patient A4 MTP dated 7/4/18 treatment intervention Psychoeducation groups on: "Cognitive and Behavioral Therapy to improve self -care and symptom management." There were no group notes or discharge planning notes that addressed discharge planning.

5. Patient A5 MTP dated 5/23/18 treatment intervention Psychoeducation groups on "Cognitive and Behavioral Therapy, Relapse Prevention to develop self-care skills". There were no group progress notes or discharge planning notes by social service.

6. Patient A6 MTP dated 7/26/18 had an incomplete treatment plan therefore there were no interventions written for progress notes to address.

7. Patient A7 MTP dated 7/11/18 did not contain discharge planning notes that addressed discharge criteria.
8.Patient A8 MTP dated 7/23/18 did not contain discharge planning notes that addressed discharge criteria.

Nursing Progress Notes:

Nursing Progress Notes and Behavioral Health Staff (BHS) were essentially check off sheets. The Nursing Progress notes were a check off sheet that contained areas such as "Safety/Risk; Appearance; Perception; Insight; Activity Level; Orientation; Judgement; Speech; Mood; Thought process and content." The areas were the same for all three shifts. There was, also, a place for a narrative for all three shifts.

The BHS Progress Notes consisted of a check off sheet for day and evening shift. It consisted of areas addressing "Program Participation; ADL's; Mental Status; Voiding/bowel movement and Appetite." There was a place for a narrative for day and evening shift.

The Nursing Progress notes and the BHS progress notes did not relate to interventions by the nursing staff in all eight (8) active sample patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8).

II. Staff Interview:

In an interview with the Director of Nursing and the Director of Clinical Programming on 8/8/18 at 3:30 p.m. the Director of Nursing acknowledged that the progress notes were not correlated with the interventions or were absent.

III. Policy Review:

Section/Page 600.10 Last Reviewed 4/14. Subject: 16 Hour RN Clinical Progress Note: Procedure: 2. "Significant behaviors, situations, description, explanations, and treatment plan's progress will be documented in the 16- Hour RN Clinical Progress Notes.

Section/Page 200.92.01 Date Revised 12/08 Subject: Group Progress Notes. Procedure: 4.0 In event that the patient doesn't attend group, a note should be completed to record their absence.

Based on record review and staff interview the medical director failed to ensure that;

1. The Psychiatric Evaluations included:

a) an assessment and/or estimation of patients' memory and/or intellectual functioning for five (5) of eight (8) patients (Patients A1,A2,A3,A5 and A8). (For details refer to B116)

b) an inventory of patients' assets for six (6) of eight (8) patients (Patients A1,A2, A4,A5, A6 and A8). (For details refer to B117)

2. Multidisciplinary, individualized, Comprehensive Treatment plan (MTP) had been developed for one (1) of eight (8) patients (Patient A6). (For details refer to B118)

Also, that MTPs included a substantiated diagnosis for 1of 8 patients(Patient A1). (For details refer to B120).

Also, that MTPs included appropriate STGs and LTGs for 8of 8 patients (Patients A1, A2, A3, A4, A5, A6, A7 and A8). (For details refer to B121)

Also, that MTPs contained individualized treatment interventions of sufficient duration and intensity/frequency, that addressed the identified problems of the patients. (For details refer to B122)

Also, that MTPs identified responsible staff by name and discipline for 6 of 8 patients (Patients A1, A2, A3, A5, A6and A8). (For details refer to B123)

3. Provide sufficient numbers of structured therapeutic activities for 1of 8 patients (Patient A3) that included alternative treatments for a patient unable/unwilling to attend group therapy. (For details refer to B125).

Based on record review and staff interview, the Director of Nursing failed to monitor psychiatric nursing care, provide adequate oversight, and take corrective actions to ensure quality nursing services. Specifically, the DON failed to:

1. Provide comprehensive treatment plans for one (1) of the eight (8 active sample patients(A6). The treatment plan was incomplete and as a result the staff was unable to provide direction and interventions to address the patient's identified problems. (Refer to B118)

2. Identify patient's strengths upon which to assist in determining the patient's goals in seven (7) out of eight (8) active sample patients. (Refer to B119)

3. Develop short term goals that were individualized for each patient based on their specific problems in eight (8) of eight (8) active sample patients. (Refer to B121)

4. Identify interventions that were specific to the goals and were not routine nursing functions in eight (8) of eight (8) active sample patients. (Refer to B122)

5. Ensure progress notes related to the treatment interventions in eight (8) active sample patients. (Refer to B126)

The Director of Social Work failed to assure the quality and appropriateness of services provided by the social work staff. Specifically:

1. The Director failed to ensure that the Psychosocial Assessments included the anticipated social work roles in treatment including appropriate interventions for identified high risk behaviors for eight (8) of eight (8) patients (Patients A1, A2, A3, A4, A5, A6, A7and A8). (For details refer to B108)

2. The Director failed to provide appropriate professional oversight for treatment/progress notes and Psychosocial Assessments performed by non MSW qualified staff for five (5) of eight (8) patients (Patients A1, A2, A4, A6 and A7) according to nationally accepted professional social work standards of practice. (For details refer to B108)

3. The Director failed to ensure that the social services staff documented treatment/progress notes that related to goals and interventions in the MTPs. (For details refer to B132)