HospitalInspections.org

Based on document review and interview, the facility's Governing Body failed to ensure that services performed under a contract are assessed and monitored in the quality assessment and improvement program for contracted services; and failed to ensure contracted services related to nursing services were furnished appropriately for 1 of 1 (Director of Nursing Services) contract agreement reviewed.


Findings include:


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1. Review of the facility's Governing Board Bylaws, last adopted 4/5/2016, on page 11, Section 6. QUALITY ASSURANCE/RISK MANAGEMENT COMMITTEE indicated the following, "The Quality Assurance/Risk Management Committee shall be responsible for monitoring and making recommendations for the implementation and improvement of the quality assurance/quality improvement program of the Corporation."

2. Review of the facility's Medical Staff Bylaws, last adopted 2/3/2015, on page 9, Section 3. OUTCOMES AND PERFORMANCE IMPROVEMENT COMMITTEE, line 10, indicated the following, "The committee will annually review contracts and services for the Inpatient Care Center (ICC) at Porter-Starke Services, Inc."

3. Review of the facility's QUALITY IMPROVEMENT PLAN, last reviewed 12/20/2013, indicated the following:
A. does not include and/or identify which facility committee is responsible for assessing and monitoring contracted services.
B. does not include contracted services for evaluation or outcomes.

4. Review of Governing Board Quality Assurance Committee meeting minutes for January through November 2016, indicated the following:
A. no reflection of Quality Assurance for contracted services for the ICC.
B. it could not be determined that contracted services were assessed and monitored for the ICC.

5. In interview with facility staff member # 1 (Vice President of Clinical Services), on 12/7/16 at 3:50 pm and staff member # 2 (Director ICC), on 12/8/16 at 9:30 am, the following was confirmed:
A. that there are different committees that report to the Governing Board, although unable to identify path of contracted service monitoring.
B. that contracted services are not included in the facility's Quality Improvement Plan.
C. "not sure" if all contracted services are reviewed and/or reported to the Governing Board.

6. No other documentation was provided prior to exit.

7. Review of the Contractual Agreement between contracted staff 20 (Consulting Director of Nursing) and staff 2 (Director ICC) on 12/6/16 at approximately 1040 hours indicated on:
A. pg. 1, under Contract section, staff 20 "shall provide up to two (2) hours of on-site consultation per rolling calendar year quarter beginning on December 14, 2009. The quarterly schedule shall consist as such:
(1). Q1: December, January, February;
(2). Q2: March, April, May;
(3). Q3: June, July, August;
(4). Q4: September, October, November."
B. pg. 2, under Contracted Duties and Responsibilities section, staff 20 "shall provide consultation pertaining to medical and nursing services offered by the registered nurses employed through [facility] services. Typed meeting minutes shall be transcribed by [facility] and reviewed and signed by staff 20 at the next meeting. Staff 20 is also required to keep a supervisor's log of each meeting to include the date, location, those in attendance, topics and outcomes of the meeting, but shall not include patient names or other identifying individual personal health information about the patients. In the event of an audit or inspection, the log shall be made available to [facility] within 24 hours."
C. pg. 3, the contract was signed and dated 12/11/2009 by staff 19 (Chief Executive Officer), but was only signed by staff 20 and not dated.

8. Staff 16 (Inpatient Nursing Supervisor and Infection Control Preventionist) was interviewed on 12/7/16 at approximately 1200 hours and confirmed, they were also considered the Director of Nursing and that staff 20 was a contracted consultant for nursing services. Staff 16 was on maternity leave from 9/16 through 12/7/16 and staff 20 was supposed to be available for consulting advice related to Director of Nursing services.

9. Staff 2 (Director ICC) was interviewed on 12/8/16 at approximately 1645 hours and confirmed, staff 20 was a contracted consultant for nursing services providing consulting advice related to Director of Nursing services while staff 16 was on maternity leave, as well as from 12/11/09 to present. However, staff 2 was unable to provide any typed meeting minutes or a supervisor's log from staff 20. The contract was signed by staff 20, but not dated.

Porter-Starke Services was found not in compliance with 42 CFR 482.13 Patient Rights.
Based on document review and observation, the facility failed to ensure personal privacy for 9 of 9 (111-1 through 119-2) patient rooms toured (see tag A143), failed to ensure patients received care in a safe setting for 2 of 2 (patients N1 and N2) patients with suicide attempt (see tag A144), failed to ensure two of two dieticians reviewed had training in the use of nonphysical intervention skills (see tag A200), failed to ensure two of two dieticians reviewed had cardiopulmonary resuscitation (CPR) training (see tag A206), and failed to ensure two of two dieticians reviewed had crisis prevention (CPI) training documented in personnel files (see tag A208).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure patient rights were promoted and protected.

Based on document review and observation, the facility failed to ensure personal privacy for 9 of 9 (111-1 through 119-2) patient rooms toured.

Findings:

1. Policy titled, "Client Rights and Responsibilities" revised/reapproved 12/13, indicated on pg. 1, under Your Rights section, bulleted points, "You are entitled to a reasonable level of personal privacy, unless your clinical condition makes this unsafe."

2. While on tour of the Inpatient Care Center (ICC) on 12//8/16 at approximately 1715 hours, in the company of staff 2 (Director ICC), it was observed in patient rooms 111-1 to 119-2 that curtains had been removed for patient safety, but the windows are large and transparent and some of the rooms are adjacent to a hill side, which makes it possible for anyone outside the room to view the patients activities inside the room not allowing for privacy.

Based on document review, observation and interview, the facility failed to ensure patients received care in a safe setting for 2 of 2 (patients N1 and N2) patients with suicide attempt.

Findings:

1. Policy titled, "Client Rights and Responsibilities" revised/reapproved 12/13, indicated on pgs. 1 and 2, under Some rights may never be suspended section, bulleted points, "The right to humane care and protection from harm...The right to receive care in a safe setting."

2. Review of Incident Reports on 12/5/16 at approximately 1300 hours, indicated patient:
A. N2 attempted suicide by hanging on 9/20/16 at 1100 hours when staff walked into patient's room and found him/her standing on the shelf in their clothes wardrobe with a piece of bed sheet ripped and tied through a hole in the upper corner of the wardrobe and the other end of the bed sheet wrapped around his/her neck. When the client saw staff approaching, he/she buckled his/her knees in an attempt to hang himself/herself. Staff rushed to client and proceeded to lift the client up to keep him/her from choking. Other staff arrived immediately and cut the bed sheet to let the client down. Client was assessed by the Nurse Practitioner and found to be medically stable and not transferred out of the facility.
B. N1 attempted suicide by hanging on 11/2/16 at 0659 hours when client was found unconscious in his/her bathroom with their gown knotted around their neck and attached to the exposed toilet pipe. Their gown was cut away and no carotid or radial pulse was noted and their skin remained warm and dry with no cyanosis noted in facial area or around lips. 911 was called by staff, cardiopulmonary resuscitation was administered, no shocks indicated to be given with the Automatic External Defibrillator and the client was transported via ambulance to an acute care hospital facility.

3. While on tour of the facility on 12/7/16 and 12/8/16 at approximately 1130 and 1221 hours, in the company of staff 2 (Director Inpatient Care Center), the following hanging hazards that may be used to tie something around were observed and photographed in patient room:
A. 111-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknob (one on each side of patient room door) that stick out;
(10). metal loops on the sides and ends of the bed frames.

B. 112-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknob (one on each side of patient room door) that stick out.

C. 113-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). smoke detector cover with multiple rectangular holes;
(8). metal doorknob (one on each side of patient room door) that stick out.

D. 114-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknob (one on each side of patient room door) that stick out.

E. 115-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknob (one on each side of patient room door) that stick out.

F. 116-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). smoke detector cover with multiple rectangular holes;
(8). metal doorknob (one on each side of patient room door) that stick out;
(9). large rectangular thermostat cover.

G. 117-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknob (one on each side of patient room door) that stick out;
(10). metal loops on the sides and ends of the bed frames.

H. 118 (seclusion room):
(1). a blind spot to the left front corner of the room by the bathroom door when the main door is closed and the patient cannot be seen from the small square window in the door;
(2). exposed toilet and sink pipes;
(3). sink faucet and handles;
(4). large rectangular bathroom light;
(5). shower control handle;
(6). metal doorknob (one on each side of patient room door) that stick out;
(7). metal loops on the sides and ends of the bed frames;
(8). large rectangular thermostat cover.

I. 119-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknob (one on each side of patient room door) that stick out;
(10). metal loops on the sides and ends of the bed frames.

4. Review of the Inpatient Care Center (ICC) census list on 12/5/16 at approximately 1200 hours indicated their were 10 patients on the unit in rooms 111-1, 112-1, 113-1, 114-2, 115-1, 115-2, 116-1, 116-2, 117-1 and 119-2.

5. Staff 6 (Psych Tech) was interviewed on 12/7/16 at approximately 1145 hours and confirmed, when asked if he/she was afraid patients could or would hang themselves in their patient rooms he/she stated "yes".

Based on document review and staff interview, the hospital failed to ensure two of two dieticians reviewed had training in the use of nonphysical intervention skills.

Findings include:

1. Review of policy titled "CPR and CPI," last reviewed on "June 5, 2014," read: "All staff with direct client contact will be required to maintain a valid CPR and CPI certification throughout their employment at Porter-Starke Services beginning with their Porter-Starke orientation program..." and "Under no circumstances will a non-certified staff member be permitted to work with clients..."

2. Review of personnel records for Dietician #L1 and Dietician #L2 indicated the dieticians did not have documentation of crisis prevention (CPI ) training.

3. Review of patient records indicated Dietician #L1 performed a nutritional assessment for Patient #L1 on 12-2-2016, without current CPI certification.

4. In interview on 12-6-2016 at 10:19 AM, Staff Member #11 indicated CPI certification is required for dieticians.

Based on document review and staff interview, the hospital failed to ensure two of two dieticians reviewed had cardiopulmonary resuscitation (CPR) training.

Findings include:

1. Review of policy titled "CPR and CPI," last reviewed on "June 5, 2014," read: "All staff with direct client contact will be required to maintain a valid CPR and CPI certification throughout their employment at Porter-Starke Services beginning with their Porter-Starke orientation program..." and "Under no circumstances will a non-certified staff member be permitted to work with clients..."

2. Review of personnel records for Dietician #L1 and Dietician #L2 indicated the dieticians did not have documentation of CPR training.

3. Review of patient records indicated Dietician #L1 performed a nutritional assessment for Patient #L1 on 12-2-2016, without current CPR.

4. In interview on 12-6-2016 at 10:19 AM, Staff Member #11 indicated CPR certification is required for dieticians.

Based on document review and staff interview, the hospital failed to ensure two of two dieticians reviewed had crisis prevention (CPI) training documented in personnel files.

Findings include:

1. Review of policy titled "CPR and CPI," last reviewed on "June 5, 2014," read: "All staff with direct client contact will be required to maintain a valid CPR and CPI certification throughout their employment at Porter-Starke Services beginning with their Porter-Starke orientation program..." and "Under no circumstances will a non-certified staff member be permitted to work with clients..."

2. Review of personnel records for Dietician #L1 and Dietician #L2 indicated the dieticians did not have documentation of CPI training.

3. Review of patient records indicated Dietician #L1 performed a nutritional assessment for Patient #L1 on 12-2-2016, without current CPI certification.

4. In interview on 12-6-2016 at 10:19 AM, Staff Member #11 indicated CPI certification is required for dieticians.

Porter-Starke Services was found not in compliance with 42 CFR 482.21 QAPI.
Based on document review, the facility failed to ensure the Safety Program measured, analyzed and tracked adverse patient events for 2 of 2 (N1 and N2) patients with suicide attempt (see tag A286) and failed to ensure that the facility's Quality Assessment and Performance Improvement Program (QAPI) reflects the complexity of the hospital's organization and services (see tag A308).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure it had an effective quality assessment and performance program.

Based on document review, the facility failed to ensure the Safety Program measured, analyzed and tracked adverse patient events for 2 of 2 (N1 and N2) patients with suicide attempt.

Findings:

1. Policy #SC-01 titled, "Safety & Risk Management Committee" revised/reapproved 2/27/07, indicated on pg. 1, under Purpose section, "The Safety & Risk Management Committee is a sub-committee of the Medical Staff Executive Committee and shall report via meeting minutes. The Safety & Risk Management Committee is responsible for developing, implementing and maintaining a continuous process of identifying and preventing conditions, circumstances or activities that may cause injury to clients, visitors and staff."

2. Review of Incident Reports on 12/5/16 at approximately 1300 hours, indicated patient:
A. N2:
(1). attempted suicide by hanging on 9/20/16 at 1100 hours when staff walked into patient's room and found him/her standing on the shelf in their clothes wardrobe with a piece of bed sheet ripped and tied through a hole in the upper corner of the wardrobe and the other end of the bed sheet wrapped around his/her neck. When the client saw staff approaching, he/she buckled his/her knees in an attempt to hang himself/herself. Staff rushed to client and proceeded to lift the client up to keep him/her from choking. Other staff arrived immediately and cut the bed sheet to let the client down. Client was assessed by the Nurse Practitioner and found to be medically stable and not transferred out of the facility.
(2). an internal review was conducted by the facility and the incident was stated as being discussed by the Risk Management Committee on 9/21/16, but meeting minutes only state "Incident at ICC (Inpatient Care Center) on 9/20/16 was announced by [staff 2, Director of ICC]; discussion ensued ". There are no further notes related to this discussion.
(3). the critical incident report also stated it would be reviewed in the Medical Staff meeting 10/5/16, but a review of these meeting minutes on 12/6/16 at approximately 1226 hours lacked any notes about discussing it.
(4). the critical incident report also stated it would be reviewed in the Risk Management Committee meeting in October (specific date not listed), but review of the meeting minutes dated 10/19/16 on 12/6/16 at approximately 1226 hours lacked any notes about discussing it.

B. N1:
(1). attempted suicide by hanging on 11/2/16 at 0659 hours when client was found unconscious in his/her bathroom with their gown knotted around their neck and attached to the exposed toilet pipe. Their gown was cut away and no carotid or radial pulse was noted and their skin remained warm and dry with no cyanosis noted in facial area or around lips. 911 was called by staff, cardiopulmonary resuscitation was administered, no shocks indicated to be given with the Automatic External Defibrillator and the client was transported via ambulance to an acute care hospital facility.
(2). incident had not been discussed in meetings by the Risk Management Committee, Medical Staff or the Safety Program Committee as of the survey date of 12/5/16 through 12/8/16.

Based on document review and interview, the facility's Governing Body failed to ensure that the facilitiy's Quality Assessment and Performance Improvement Program (QAPI) reflects the complexity of the hospital's organization and services.

Findings:

1. Review of the facility's Governing Board Bylaws, last adopted 4/5/2016, on page 17, Section 6. QUALITY ASSURANCE, indicated the following; "The Medical Staff shall adopt a plan of quality assurance to govern its members that includes effective mechanisms for reviewing and evaluating patient care, as well as an appropriate response to findings. Such quality assurance plan shall be effective upon and subject to, approval by the Board of Directors. At least quarterly, the President of the Medical Staff shall submit to the Board of Directors, a written report of its quality assurance acitivities, including a summary of its findings and its recommendations for methods to improve patient care."

2. Review of the facility's Medical Staff Bylaws, last adopted 2/3/2015, indicated the following:
A. that there are 3 identified commitees related to quality and outcomes: "Outcomes and Performance Improvement Committee", Risk Management Committee" and "Pharmacy and Therapeutics Committee"
B. Unable to determine if the Risk Management Committee reports to Medical Staff Executive Committee
C. Unable to determine if the 3 Committees all report to the Governing Board
D. Unable to determine if the 3 Committess are part of the hospital's QAPI

3. Review of the facility's QUALITY IMPROVEMENT PLAN, last reviewed 12/20/2013, indicated the following:
A. Does not include language in regards to the various committees of: Outcomes and Performance, Risk Management, Pharmacy and Therapeutics, Quality Assurance and Safety
B. Does not include language in regards to frequency of meetings of various committees and the path to which reports go to the Governing Board
C. Not able to determine that the facility's Quality Improvement Plan reflects organization overall

4. In interview with facility staff member # 1 (Vice President of Clinical Services), on 12/7/16 at 3:50 pm, and 12/8/16 at 9:00 am, and staff member # 2 (Director Inpatient Care Center), on 12/8/16 at 9:30 am, the following was confirmed:
A. that there are different committees with similar names, that meet at different times within the calendar year, which are not included in the Quality Improvement Plan
B. that it is not clear as to what path the reports of the different committees goes to Medical Executive Committee and/or the Governing Board, or if all the committee reports are actually forwarded up
C. Outcome Committee Meetings go through Strategic Plan, before going to the Board, although Strategic Plan is not part of the Quality Improvement Plan
D. No other documentation was provided prior to exit.

Porter-Starke Services was found not in compliance with 42 CFR 482.23 Nursing Services.
Based on document review and interview, the facility failed to ensure there was a well-organized nursing service with a plan of administrative authority and delineation of responsibilities for patient care related to Director of Nursing Services (see tag 386, failed to ensure adequate staffing of Psychiatric Technicians to meet patient needs for 1 of 4 (Inpatient Care Center [ICC]) areas toured (see tag A392), failed to supervise and evaluate the nursing care for each patient related to lack of completion of a suicide risk assessment on admission and discharge for 3 of 10 (N2, N8 and N10) patient medical records reviewed and lack of following physician orders related to insulin sliding scale for 1 of 10 (N5) patient medical records reviewed (see tag A395), failed to ensure specialized qualifications and/or competence of nursing personnel to meet patient needs related to lack of point of care testing training for 5 of 5 (7, 16, 21, 22 and 23) registered nurse personnel files reviewed (see tag A 397), and failed to ensure drugs and biologicals were administered appropriately in 1 of 4 (Medication Room) areas toured (see tag A405).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure it had an organized nursing service.

Based on document review and interview, the facility failed to ensure there was a well-organized nursing service with a plan of administrative authority and delineation of responsibilities for patient care related to Director of Nursing Services.

Findings:

1. Review of the Contractual Agreement between contracted staff 20 (Consulting Director of Nursing) and staff 2 (Director Inpatient Care Center [ICC]) on 12/6/16 at approximately 1040 hours indicated on pg:
A. 1, under Contract section, staff 20 "shall provide up to two (2) hours of on-site consultation per rolling calendar year quarter beginning on December 14, 2009. The quarterly schedule shall consist as such:
(1). Q1: December, January, February;
(2). Q2: March, April, May;
(3). Q3: June, July, August;
(4). Q4: September, October, November."

B. 2, under Contracted Duties and Responsibilites section, staff 20 "shall provide consultation pertaining to medical and nursing services offered by the registered nurses employed through [facility] services. Typed meeting minutes shall be transcribed by [facility] and reviewed and signed by staff 20 at the next meeting.

C. 3, the contract was signed and dated 12/11/2009 by staff 19 (Chief Executive Officer), but was only signed by staff 20 and not dated.

2. Staff 16 (Inpatient Nursing Supervisor and Infection Control Preventionist) was interviewed on 12/7/16 at approximately 1200 hours and confirmed, they were also considered the Director of Nursing and that staff 20 was a contracted consultant for nursing services. Staff 16 was on maternity leave from 9/16 through 12/7/16 and staff 20 was supposed to be available for consulting advice related to Director of Nursing services.

3. Staff 2 (Director ICC) was interviewed on 12/8/16 at approximately 1645 hours and confirmed, staff 20 was a contracted consultant for nursing services providing consulting advice related to Director of Nursing services while staff 16 was on maternity leave, as well as from 12/11/09 to present. However, staff 2 was unable to provide any typed meeting minutes from staff 20. The contract was signed by staff 20, but not dated. There was no designated Director of Nursing while staff 16 was on maternity leave.

Based on document review and interview, the facility failed to ensure adequate staffing of Psychiatric Technicians to meet patient needs for 1 of 4 (Inpatient Care Center [ICC]) areas toured.

Findings:

1. Policy #1.05 titled, "Clinical Staffing Plan" revised/reapproved 12/13, indicated on pg. 1, under Purpose and Procedure sections, points 1. and 4., "To provide adequate and safe staffing for clients...The ICC is a 24-hour-a-day, seven day a week unit and is covered by three eight-hour shifts. Clinical staff consists of Registered Nurses, Psych Techs, and Social Workers...On a daily basis it may be necessary to adjust the staff pattern for acuity, call offs, or low census."

2. Review of the Incident Report for patient N1 for an incident that occurred on 11/2/16 indicated, staffing would be increased to include a security guard on midnight shift and addition of a psychiatric technician on weekend day and evening shifts.

3. Review of Psych Tech schedules from 11/20/16 through 12/8/16 indicated, an additional psychiatric technician was not scheduled on the weekend days of 11/26/16 and 12/3/16, and on the evening shifts of 12/4/16 and 12/7/16.

4. Staff 2 (Director ICC) was interviewed on 12/8/16 at approximately 1645 hours and confirmed, psychiatric technician's were not scheduled on the above-mentioned dates.

Based on document review and interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of completion of a suicide risk assessment on admission and discharge for 3 of 10 (N2, N8 and N10) patient medical records reviewed; and lack of following physician orders related to insulin sliding scale for 1 of 10 (N5) patient medical records reviewed.

Findings:

1. Policy #6.07 titled, "Suicide Assessment and Intervention", revised/reapproved 8/16 and in effect for patient N2, indicated on pg. 1, under Procedure section, point 1., "Suicide risk assessments will be done for all clients upon admission and again on discharge."

2. Policy #5.07 titled, "Suicide Assessment and Tiered Intervention", revised/reapproved 12/16 and in effect for patients N8 and N10, indicated on pg. 1, under Procedure section, point 1., "Suicide risk assessments will be done for all clients upon admission and again on discharge by the nursing staff."

3. Review of patient medical records on 12/5/16 at approximately 1540 hours indicated patient:
A. N2 was admitted on 9/19/16 and discharged 9/24/16 and:
(1). Inpatient Evaluation on 9/19/16 indicated chief complaint was "I tried to kill myself" and patient was admitted to the Inpatient Care Center (ICC) because of depressed mood and after a suicide attempt.
(2). History and Physical on 9/19/16 indicated patient was admitted with suicidal ideation.
(3). The medical record lacked a Suicide Risk Assessment on admission and discharge.

B. N8 was admitted on 12/7/16 and transferred 12/8/16 and:
(1). Inpatient Evaluation on 12/7/16 indicated patient "started feeling suicidal with a plan" and patient was admitted to the ICC.
(2). Physician's Orders dated 12/7/16 indicated patient was to be on level 3 precautions for "every 5 minute" checks due to suicidal ideation.
(3). The medical record lacked a Suicide Risk Assessment on admission and discharge.

C. N10 was admitted on 12/7/16 and transferred 12/8/16 and:
(1). Inpatient Evaluation on 12/7/16 indicated patient had "current active suicidal ideation and a recent suicide attempt or gesture within 72 hours prior to admit" and patient was admitted to the ICC.
(2). Physician's Orders dated 12/7/16 indicated patient was to be on level 3 precautions for "every 5 minute" checks due to suicidal ideation.
(3). The medical record lacked a Suicide Risk Assessment on admission and discharge.

4. Policy #6.05 titled, "Physician's Orders", revised/reapproved 12/13, indicated on pg. 1, under Procedure section, points 1. and 4., "Orders recorded on the Physician's Order Sheet pertain to...medication treatments...Must be completely understood before being carried out."

5. Review of patient medical records on 12/5/16 at approximately 1540 hours indicated patient:
A. N5 was admitted on 12/7/16 and transferred 12/8/16 and:
(1). had a continuous insulin pump that was discontinued on admission.
(2). Physician's Orders dated 11/22/16 at 0445 hours indicated a Novolog Insulin Sliding Scale for a blood sugar range of:
a. 61-150 = no insulin;
b. 151-200 = 3 units Novolog given subcutaneously (SQ);
c. 201-250 = 5 units Novolog SQ;
d. 251-300 = 8 units Novolog SQ;
e. 301-350 = 10 units Novolog SQ;
f. 351-400 = 12 units Novolog SQ;
g. > 400 = 15 units Novolog SQ and call provider.
(3). patient's blood sugar level was not documented on 11/22/16 at 0445 hours on the Glucometer/Insulin Record, but 8 units of Novolog was given SQ.
(4). patient's blood sugar level was 161 on 11/22/16 at 0715 hours and no insulin was given, but according to the Novolog Insulin Sliding Scale above the patient should have been given 3 units Novolog SQ.
(5). at 1235 hours on 11/22/16, the Novolog Insulin Sliding Scale order above was discontinued and Physician's Orders changed for a blood sugar range of:
a. 61-120 = 11 units Novolog SQ;
b. 121-170 = 13 units Novolog SQ;
c. 171-220 = 15 units Novolog SQ;
d. 221-270 = 17 units Novolog SQ;
e. at bedtime (HS) blood glucose of 250-300 = 5 units Novolog SQ;
f. HS blood glucose of 301-350 = 10 units Novolog SQ;
g. continue to check blood sugar level at meal times and call Medical Director if it exceeds 250/270.
(6). at 1425 on 11/22/16, patient's blood sugar level was 358 and 5 units Novolog was given SQ and the Medical Director was not called.
(7). at 0210 hours on 11/23/16, patient's blood sugar level was 179 and no insulin was given.

6. Staff 16 (Inpatient Nursing Supervisor and Infection Control Preventionist) was interviewed on 12/7/16 at approximately 1200 hours and confirmed, nursing staff was supposed to complete a Suicide Risk Assessment on admission and discharge for patient N2 according to policy #6.07. The policy was revised on 12/16 and a physician, not nursing staff, was supposed to complete a Suicide Risk Assessment on admission and discharge for patients N8 and N10 according to policy #5.07. The Suicide Risk Assessment was not completed on admission and discharge for the above-mentioned patients as required by facility policy and procedure. Physician's Orders were also not followed as required by facility policy and procedure.

Based on document review and interview, the facility failed to ensure specialized qualifications and/or competence of nursing personnel to meet patient needs related to lack of point of care testing training for 5 of 5 (7, 16, 21, 22 and 23) registered nurse personnel files reviewed.

Findings:

1. Policy #4.02 titled, "Urine Drug Screen and Pregnancy Screen Collection" revised/reapproved 7/16, indicated on pg. 1, under Procedure section, point 1., "Upon admission, female clients will be ordered a urine pregnancy screening and all clients will be ordered a urine drug screen."

2. Policy titled, "Glucometer" revised/reapproved 11/16, indicated on pg. 1, under Purpose section, "To ensure proper glucose levels on clients obtaining care at the Inpatient Care Center."

3. Review of personnel files on 12/5/16 and 12/6/16 at 1354 and 0930 hours, indicated staff 7, 16, 21, 22 and 23 were registered nurses and lacked training related to point of care testing for pregnancy screening, urine drug screening and obtaining blood glucose levels on patients.

4. Staff 16 (Inpatient Nursing Supervisor and Infection Control Preventionist) was interviewed on 12/7/16 at approximately 1200 hours and confirmed, the above-mentioned personnel receive point of care testing annually and had not completed it for this year.

Based on observation and interview, the facility failed to ensure drugs and biologicals were administered appropriately in 1 of 4 (Medication Room) areas toured.

Findings:

1. While on tour of the facility on 12/7/16 and 12/8/16 at approximately 1130 and 1221 hours, in the company of staff 7 (Registered Nurse), it was observed in the Medication room that 3 vials of sterile water were labeled as single-use and were open, but lacked date and initials. Two vials were lot #50-057-DK, expiration date 2/1/18 and one vial was lot #54-151-DK, expiration date 6/1/18.

2. Staff 7 was interviewed on 12/8/16 at approximately 1250 hours and confirmed, the above-mentioned single-use vials were open, lacked date and initials and were being used for multiple patients. There is no policy related to administration of single-use medications.

Porter-Starke Services was found not in compliance with 42 CFR 482.27 Laboratory Services. Based on document review and staff interview, the hospital failed to have a contractual agreement to provide laboratory services for 17 of 17 tests performed by an outside laboratory (see tag A582), failed to determine which laboratory services were to be immediately available 24 hours a day to meet the emergency needs of patients for 18 of 18 laboratory tests reviewed (see tag A583), and failed to have a written description of laboratory services provided for 18 of 18 laboratory tests reviewed (see tag A584).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure it proved adequate laboratory services to meet the needs of the patients.

Based on document review and staff interview, the hospital failed to have a contractual agreement to provide laboratory services for 17 of 17 tests performed by an outside laboratory.

Findings include:

1. Review of patient medical records indicated the following:
a. Patient #L1 (admitted on 12-2-2016) had the following tests performed by an outside laboratory:
1) On 12-2-2016: cholesterol, triglycerides, high density lipoprotein, and thyroid stimulating hormone; tests were ordered by Physician #L100 on 12-1-2016, upon admission at "1730."
2) On 12-3-2016: magnesium and phosphorus; tests were ordered by Physician #L101 on 12-2-2016 at "2pm."
3) On 12-4-2016: thyroxineCQ; test was ordered by Physician #L100 on 12-2-2016, upon admission "1730."
b. Patient #L2 (admitted on 12-4-2016) had the following tests performed by an outside laboratory on 12-4-2016: thyroid stimulating hormone, cholesterol, triglycerides, and high density lipoprotein; tests were ordered on 12-3-2016 by Physician #L102, upon admission at "2315."
c. Patient #L3 (admitted on 12-5-2106) had the following test performed by an outside laboratory on 12-5-2016: complete blood count, sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, creatinine, glucose, calcium; tests were ordered by Physician #L103, on 12-5-2016, upon admission at "1015."
d. Patient #L4 (admitted on 12-3-2016) had the following tests performed by an outside laboratory on 12-4-2016: cholesterol, triglycerides, high density lipoprotein, and thyroid stimulating hormone; tests were ordered by Physician #L102 on 12-3-2016, upon admission at "2000."
e. Patient #L5 (admitted on 11-22-2016) had the following tests performed by an outside laboratory on 11-22-2016: complete blood count, ordered by Physician #L104, upon admission on 11-22-2016 at "0230," and lithium, ordered by Physician #L103 on 11-22-2016 at "9:30am."

2. In interview on 12-6-2016 at 2:23 PM, Staff Member #2, Director of the Inpatient Care Center, indicated the hospital did not have a contract with the laboratory performing the following patient laboratory tests: cholesterol, triglycerides, high density lipoprotein, thyroid stimulating hormone, magnesium, phosphorus, thyroxineCQ, complete blood count, sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, creatinine, glucose, calcium, and lithium.

Based on document review and staff interview, the hospital failed to determine which laboratory services were to be immediately available 24 hours a day to meet the emergency needs of patients for 18 of 18 laboratory tests reviewed.

Findings include:

1. Review of patient medical records indicated:
a. The following tests were performed on patient samples by an outside laboratory: cholesterol, triglycerides, high density lipoprotein, thyroid stimulating hormone, magnesium, phosphorus, thyroxineCQ, complete blood count, sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, creatinine, glucose, calcium, and lithium.
b. The hospital performed glucose testing in-house, using a glucometer

2. Review of policies and procedures indicated the hospital did not a written description of which laboratory tests were to be immediately available, 24 hours a day, to meet the emergency needs of patients.

3. In interview on 12-6-2016 at 2:23 PM, Staff Member #2, Director of the Inpatient Care Center, indicated the hospital did not have a written description of which laboratory tests were to be immediately available 24 hours a day for emergency needs, nor did the hospital have a contract with an outside laboratory to provide emergency laboratory services.

Based on document review and staff interview, the hospital failed to have a written description of laboratory services provided for 18 of 18 laboratory tests reviewed.

Findings include:

1. Review of patient medical records indicated:
a. The following tests were performed on patient samples by an outside laboratory: cholesterol, triglycerides, high density lipoprotein, thyroid stimulating hormone, magnesium, phosphorus, thyroxineCQ, complete blood count, sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, creatinine, glucose, calcium, and lithium.
b. The hospital performed glucose testing in-house, using a glucometer

2. Review of policies and procedures indicated the hospital did not a written description of laboratory tests provided to patients.

3. In interview on 12-6-2016 at 2:23 PM, Staff Member #2, Director of the Inpatient Care Center, indicated the hospital did not have a written description of laboratory tests provided to patients.

Based on document review, observation, and staff interview, the hospital failed to have a full-time employee who served as the food and dietetic services director and was responsible for the daily management of four of five dietary services reviewed (emergency food supplies, orientation, training programs, and personnel performance).

1. Review of personnel records for Dietician #L1 (hire date 7-23-2015)and Dietician #L2 (hire date 8-7-2015) indicated they had not participated in orientation, training programs, and their personnel performance had not been evaluated.

2. Review of policies and procedures indicated the following:
a. The hospital did not have policies and procedures for safe food handling or dietary management
b. A policy titled: "Fire and Disaster Plan," last revised "July 2015," indicate the three day disaster menu included: "Day 1: Breakfast: 3/4 Cup Dry Cereal...Lunch: 6 oz. Spaghetti..." and "Day 2: Breakfast: Sweet roll...Dinner: 2 Slices of Bread..." and "Day 3: Lunch: 1 Cheese Slice...2 Slices Bread..."

3. During facility tour on 12-6-2016 at 10:26 AM, no dry cereal, spaghetti, sweet rolls, bread, or cheese slices were observed to be stored for an emergency.

4. In interview on 12-6-2016:
a. At 10:26 AM, Dietician #L1 acknowledged the facility did not have dry cereal, spaghetti, sweet rolls, bread, or cheese slices stored for an emergency.
b. At 12:04 PM, Staff Member #2 indicated the hospital did not have a full-time employee who serves as the director of the food and dietetic services. At 1:42 PM, Staff Member #2 indicated the hospital did not have policies and procedures for food service. Staff Member #2 further indicated the hospital had policies and procedures for dietary management and competency documentation for the contracted catering service and would make them available for review. Policies and procedures for dietary management and competency documentation for the contracted catering service were not provided by exit on December 6, 2016 at 4:30 PM.

Based on Life Safety Code (LSC) and Health surveys, Porter-Starke Services was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and CFR 482.41 Physical Environment.

Building 01, a two story structure was determined to be of Type II (111) construction and was fully sprinklered. The facility lacked a two hour separation so the entire facility was surveyed under chapter 19, existing health care occupancy. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors, except as noted at K341. The facility has a capacity of 16 and had a census of 9 at the time of this survey.

Based on record review, observation and interview, the facility failed to ensure 1 of 1 fire barrier walls was protected (see tag A709), failed to ensure 3 of 8 corridors access were in accordance with Chapter 7 (see tag A709), failed to ensure emergency lighting was provided for 8 of 8 exits (see tag A711), failed to install exit signage in 1 of 8 corridors in the facility (see tag A709), failed to maintain protection of 1 of 3 stairway in accordance of 19.3.1. LSC 8.6.8 (see tag A709), failed to maintain protection of 1 of 3 stairway in accordance of 19.3.1 (see tag A709), failed to ensure 1 of 1 Health Information Management storage room greater than fifty square feet was protected in accordance with 19.3.2.1.5. LSC 19.2.1.3 (see tag A709), failed to ensure 1 of 1 kitchen exhaust system was completely maintained (see tag A701), failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 (see tag A709), failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 (see tag A701), failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6 (see tag A714), failed to ensure the
spray pattern for sprinkler heads were not obstructed in 1 of 1 North Staff Entrance Stairwell and 1 of 9 resident rooms in accordance with 19.3.5.1. NFPA 13, 2010 edition, Section 8.5.5.1 (see tag A709), failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 (see tag A701), failed to provide a 1 of 1 written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 (see tag A714), failed to ensure 1 of 1 Boiler room and 1 of 1 Kitchen portable fire extinguishers was installed correctly in accordance with 19.3.5.12. NFPA 10 (see tag A709), failed to ensure 1 of 2 Recovery corridor was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 19.3.6.1(7) (see tag A709), failed to maintain protection of 1 of 8 corridor walls in accordance of 18.3.6.2. LSC 18.3.6.2 (see tag A709), failed to maintain protection of corridor doors and had no impediment to latching in 5 of 8 corridors in accordance of 19.3.6.3 (see tag A709), failed to maintain annual testing of 1 of 1 rolling fire door in accordance of 19.3.6.3.3. LSC 19.3.6.3.3 (see tag A709), failed to ensure 2 of 2 elevator equipment rooms was provided with an electrical shunt trip when provided with sprinkler coverage in accordance with 19.5.3. ASME/ANSI A17.1 (see tag A709), failed to provide a written plan that addressed all components in 1 of 1 written fire plans (see tag A714), failed to conduct quarterly fire drills for 4 of 4 quarters. LSC 19.7.1.6 (see tag A709), failed to ensure 1 of 1 East Entrance Overhang was maintained in accordance with 19.7.5.1. LSC 19.7.5.1 (see tag A709), failed to ensure 1 of 1 candle was maintained in accordance with 19.7.5.6. LSC 19.7.5.6 (see tag A709), failed to ensure 24 of 24 space heaters was equipped with a heating element which would not exceed 212 degrees Fahrenheit (F) in accordance with 19.7.8. LSC 19.7.8 (see tag A709), failed to ensure 1 of 1 generator was accordance with 6.4.4.1.1.3. 2010 NFPA 110 8.4.2.3 (see tag A701), failed to ensure 16 of 16 flexible cords were not used as a substitute for fixed wiring nor with a high current draw according to 9.1.2. LSC 9.1.2 (see tag A709), and failed to ensure trash receptacles near 1 of 1 gym and 1 of 1 Dining room maintained in accordance with 19.7.5.7 (see tag K754).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review, observation and interview, the facility failed to ensure the condition of the physical plant and hospital environment was constructed and maintained to ensure the safety and well-being of patients related to hanging hazards in 9 of 9 patient rooms toured (room 111-1 to 119-2) and maintainenece of 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing, failed to ensure 1 of 1 kitchen exhaust system was completely maintained. NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition at 11.2.1 maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every 6 months, failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 7-3.2 requires testing shall be performed in accordance with the Table 14.4.5 Testing Frequencies. NFPA 72, 14.4.5.3.5 states smoke detectors or smoke alarms found to have a sensitivity range outside the listed and marked sensitivity range shall be cleaned and recalibrated or to be replaced, and failed to ensure 1 of 1 generator was accordance with 6.4.4.1.1.3. 2010 NFPA 110 8.4.2.3 states that diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPSS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Findings include;

1. Policy titled, "Client Rights and Responsibilities" revised/reapproved 12/13, indicated on pgs. 1 and 2, under Some rights may never be suspended section, bulleted points, "The right to humane care and protection from harm...The right to receive care in a safe setting."

2. While on tour of the facility on 12/7/16 and 12/8/16 at approximately 1130 and 1221 hours, in the company of staff 2 (Director Inpatient Care Center), the following hanging hazards that may be used to tie something around were observed and photographed in patient room:
A. 111-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknobs (one on each side of patient room door) that stick out;
(10). metal loops on the sides and ends of the bed frames.

B. 112-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknobs (one on each side of patient room door) that stick out.

C. 113-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). smoke detector cover with multiple rectangular holes;
(8). metal doorknobs (one on each side of patient room door) that stick out.

D. 114-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknobs (one on each side of patient room door) that stick out.

E. 115-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknobs (one on each side of patient room door) that stick out.

F. 116-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). smoke detector cover with multiple rectangular holes;
(8). metal doorknobs (one on each side of patient room door) that stick out;
(9). large rectangular thermostat cover.

G. 117-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknobs (one on each side of patient room door) that stick out;
(10). metal loops on the sides and ends of the bed frames.

H. 118 (seclusion room):
(1). a blind spot to the left front corner of the room by the bathroom door when the main door is closed and the patient cannot be seen from the small square window in the door;
(2). exposed toilet and sink pipes;
(3). sink faucet and handles;
(4). large rectangular bathroom light;
(5). shower control handle;
(6). metal doorknobs (one on each side of patient room door) that stick out;
(7). metal loops on the sides and ends of the bed frames;
(8). large rectangular thermostat cover.

I. 119-1 and 2:
(1). exposed toilet and sink pipes;
(2). sink faucet and handles;
(3). large rectangular bathroom light;
(4). shower control handle;
(5). wardrobe with clothes hanger bar with gaps on each end;
(6). hole in the upper corner of the clothes hanging wardrobe;
(7). large windows with a curtain rod with individual supports attached from the wall to the curtain rod;
(8). smoke detector cover with multiple rectangular holes;
(9). metal doorknobs (one on each side of patient room door) that stick out;
(10). metal loops on the sides and ends of the bed frames.

3. Review of Incident Reports on 12/5/16 at approximately 1300 hours, indicated patient:
A. N2 attempted suicide by hanging on 9/20/16 at 1100 hours when staff walked into patient's room and found him/her standing on the shelf in their clothes wardrobe with a piece of bed sheet ripped and tied through a hole in the upper corner of the wardrobe and the other end of the bed sheet wrapped around his/her neck. When the client saw staff approaching, he/she buckled his/her knees in an attempt to hang himself/herself. Staff rushed to client and proceeded to lift the client up to keep him/her from choking. Other staff arrived immediately and cut the bed sheet to let the client down. Client was assessed by the Nurse Practitioner and found to be medically stable and not transferred out of the facility.
B. N1 attempted suicide by hanging on 11/2/16 at 0659 hours when client was found unconscious in his/her bathroom with their gown knotted around their neck and attached to the exposed toilet pipe. Their gown was cut away and no carotid or radial pulse was noted and their skin remained warm and dry with no cyanosis noted in facial area or around lips. 911 was called by staff, cardiopulmonary resuscitation was administered, no shocks indicated to be given with the Automatic External Defibrillator and the client was transported via ambulance to an acute care hospital facility.

4. Review of the Inpatient Care Center (ICC) census list on 12/5/16 at approximately 1200 hours indicated their were 10 patients on the unit in rooms 111-1, 112-1, 113-1, 114-2, 115-1, 115-2, 116-1, 116-2, 117-1 and 119-2.

5. Staff 6 (Psych Tech) was interviewed on 12/7/16 at approximately 1145 hours and confirmed, when asked if he/she was afraid patients could or would hang themselves in their patient rooms he/she stated "yes".

6. Based on record review with the Director of Facilities Management on 12/06/16 between 8:45 a.m. and 1:00 p.m., the sprinkler system was inspected annually. No documentation was available for the monthly gauges or control valves inspection. Additionally, the five year obstruction, internal inspection of piping was not available for review. Based on observation on 12/07/16 at 8:50 a.m., the East Stairwell standpipe gauge was dated on 11/24/09. Based on interview at the time of observation, the Director of Facilities Management acknowledged the sprinkler system should be inspected quarterly, confirmed the sprinkler system was at least five years old, and the sprinkler gauge had not been recalibrated or replaced within five years.

7. Based on record review with the Director of Facilities Management on 11/07/16 between 9:04 a.m. and 10:21 a.m., the kitchen hood was being inspected annually. Based on interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

8. Based on record review with the Director of Facilities Management on 12/06/16 at 11:31 a.m., the last fire alarm sensitivity test was performed on 05/08/13 by Rask Fire and Life Safety. The last report indicated five of forty three devices failed sensitivity testing. Based on interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition and confirmed no other documentation was available for review.

9. Based on record review with the Director of Facilities Management on 12/06/16 at 11:08 a.m., the monthly documentation indicated that the generator failed to exercise with a load over thirty percent for the last twelve months. Based on an interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition and confirmed no load bank test was available for review.

10. Based on record review and interview, the facility failed to ensure a written record of weekly inspections for the generator was maintained for 28 of 52 weeks and a testing record of monthly inspections for the generator was maintained for 11 of 12 months. NFPA 99, 6.4.4.1.3 requires onsite generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 8.4.1 requires an Emergency Power Supply System (EPSS) including all appurtenant components, shall be inspected weekly and exercised monthly. NFPA 99, 6.4.4.2 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction.

11. Based on record review with the Director of Facilities Management on 12/06/16 at 11:08 a.m., the following was discovered:
a) no monthly testing for February 2016 was available for review
b) monthly testing form failed to include transfer time and a cool down period
c) twenty eight of fifty two weeks of weekly inspections were not available for review. Based on an interview at the time of record review, the Maintenance Supervisor acknowledged the aforementioned condition.


:

Based on record review, observation and interview, the facility failed to ensure 1 of 1 fire barrier walls was protected. LSC 8.3.3.1 states openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies. Table 8.3.4.2 requires 2 hour fire rated walls and partitions to have fire door assemblies with a rating of at least 1 1/2 hours fire rating, failed to ensure 3 of 8 corridors access were in accordance with Chapter 7. LSC 7.1.10.2.1 requires no furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof, failed to install exit signage in 1 of 8 corridors in the facility in accordance with LSC 7.10. LSC 7.10.1.2.1 exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access, failed to maintain protection of 1 of 3 stairway in accordance of 19.3.1. LSC 8.6.8 requires convenience openings to be open to only one floor. LSC 8.6.9 requires openings to be separated from corridors, failed to maintain protection of 1 of 3 stairway in accordance of 19.3.1., failed to ensure 1 of 1 Health Information Management storage room greater than fifty square feet was protected in accordance with 19.3.2.1.5. LSC 19.2.1.3 requires doors to hazardous areas shall be self-closing or automatic-closing,
failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors, failed to ensure the spray pattern for sprinkler heads were not obstructed in 1 of 1 North Staff Entrance Stairwell and 1 of 9 resident rooms in accordance with 19.3.5.1. NFPA 13, 2010 edition, Section 8.5.5.1, states sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.5.5.2. and 8.5.5.3 or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Section 8.5.5.2 and 8.5.5.3 do not permit continuous or noncontinuous obstructions less than or equal to 18 in. below the sprinkler deflector that prevent the pattern from fully developing, failed to ensure 1 of 1 Boiler room and 1 of 1 Kitchen portable fire extinguishers was installed correctly in accordance with 19.3.5.12. NFPA 10, the Standard for Portable Fire Extinguishers, 6.1.3.8.3 in no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 inches, failed to ensure 1 of 2 Recovery corridor was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 19.3.6.1(7). LSC 19.3.6.1(7) states that spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be open to the corridor and unlimited in area, provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, and (b) Each space is protected by an automatic sprinklers, and (c) The space does not to obstruct access to required exits, failed to maintain protection of 1 of 8 corridor walls in accordance of 18.3.6.2. LSC 18.3.6.2, Construction of Corridor Walls, requires corridor walls shall form a barrier to limit the transfer of smoke, failed to maintain protection of corridor doors and had no impediment to latching in 5 of 8 corridors in accordance of 19.3.6.3, failed to maintain annual testing of 1 of 1 rolling fire door in accordance of 19.3.6.3.3. LSC 19.3.6.3.3 requires compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80 5.2.1 requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ, failed to ensure 2 of 2 elevator equipment rooms was provided with an electrical shunt trip when provided with sprinkler coverage in accordance with 19.5.3. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room, failed to conduct quarterly fire drills for 4 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions, failed to ensure 1 of 1 East Entrance Overhang was maintained in accordance with 19.7.5.1. LSC 19.7.5.1 requires draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1, failed to ensure 1 of 1 candle was maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met, failed to ensure 24 of 24 space heaters was equipped with a heating element which would not exceed 212 degrees Fahrenheit (F) in accordance with 19.7.8. LSC 19.7.8 requires portable space-heating elements do not exceed 212 degrees, failed to ensure 16 of 16 flexible cords were not used as a substitute for fixed wiring nor with a high current draw according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure.

Findings include:

1. Based on record review with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16, the facility site plans indicated a two hour fire wall near Recovery. Based on observation at 4:36 p.m., the cross corridor door contained a twenty minute fire resistive rating tag. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

2. Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 between 2:05 p.m. and 3:06 p.m., the following was discovered:
a) two separate treadmills were in the corridor outside of the office room 256
b) two separate clothes baskets were in the corridor outside of the Laundry room
Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 8:43 a.m.,
c) a trash can was in the corridor near the Front office

3. Based on interview at the time of each observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged each aforementioned condition.

4. Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 2:37 p.m., the path from the north stairwell and south stairwell is separated by a cross corridor door near the center stairwell. Exits signs were not provided on either side of the cross corridor door. Based on interview at the time of observation, the Director of Facilities Management acknowledged the aforementioned condition.

5. Based on observation with the Maintenance Technician #1 on 12/07/16 at 8:45 a.m., the 90 minute rated double doors at the bottom of the middle stairwell, which was not considered a part of egress, had a quarter inch gap when closed and lacked positive latching hardware. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

6. Based on record review with the Maintenance Technician #1 on 12/07/16, the site plans indicated the stairwells were constructed as a two hour barrier. Based on observation at 8:32 a.m., the 1st floor West stairwell door did not have a fire protection rating tag.
Based on interview at the time of the observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

7. Based on observation with the Maintenance Technician #1 on 12/06/16 at 1:54 p.m., the room contained three open six foot tall cabinets full of paperwork. Additionally, many boxes of paperwork were stacked on the floor making it difficult to walk around. The corridor door did not have a self-closing device installed. Based on interview at the time of observation, the Director of Maintenance and the Maintenance Technician #1 acknowledged the aforementioned condition and confirmed the room was greater than 50 square feet.

8. Based on observation and interview, the facility failed to maintain protection of 1 of 1 Mechanical room in accordance of 19.3.2. This deficient practice could affect staff only.

9. Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 4:47 p.m., the Mechanical room contained natural gas fuel-fire equipment. One of the double corridor doors contained manual latching hardware. Additionally, one of the doors contained an astragal and no coordinating device installed. Inside the room near the corridor door was a wedge-shaped door stop. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned conditions.

10. Based on observation and interview, the facility failed to maintain protection of 1 of 1 Kitchen in accordance of 19.3.2. This deficient practice could affect staff only.

11. Based on observation with the Maintenance Technician #1 on 12/07/16 at 8:31 a.m., the Kitchen contained two forty gallon trash containers. One of the two corridor doors did not have a self-closing device installed. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

12. Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:20 p.m., the Experiential Therapy room had a smoke detector between two air vents. The closet air vent measured sixteen inches away. Based on interview at the time of record review, the Maintenance Technician #1 acknowledged the aforementioned condition and provided the measurement.

13. Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:59 p.m. then again at 3:21 p.m., the North Staff Entrance Stairwell sprinkler head deflector as above the hole cut out for it in the drop ceiling. Then again, resident room 118 contained two sprinkler heads within four inches of two ceiling box lights. The ceiling box lights were lower than the deflector. Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

14. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with 19.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 9.1.1.7, Support of Non-System Components, requires sprinkler piping or hangers shall not be used to support non-system components. This deficient practice could affect all occupants.

15. Based on observations with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 4:47 p.m., a conduit was zip tied to the sprinkler pipe outside the Director of Inpatient Care office. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

16. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 IT room and 1 of 1 Director of Inpatient Care in accordance with 19.3.5.1. LSC 19.3.5.3 states where required by LSC 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised, automatic sprinkler system in accordance with Section 9.7. Section 9.7 indicates that automatic sprinkler system requires shall be in accordance with NFPA 13. NFPA 13, 2010 edition, Section 8.5.4.1.1 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect staff only.

17. Based on observation with the Maintenance Technician #1 on 12/06/16 at 3:08 p.m. then again at 4:41 p.m., two of ten ceiling tiles were exposed in the IT room. Then again, one of thirty four ceiling tiles were not in place in the Director of Inpatient Care. Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

18. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Executive Stairwell in accordance with 19.3.5.1. LSC 19.3.5.3 states where required by LSC 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised, automatic sprinkler system in accordance with Section 9.7. Section 9.7 indicates that automatic sprinkler system requires shall be in accordance with NFPA 13. NFPA 13, 2010 edition, Section 6.2.7 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic, or shall be listed for use around a sprinkler. This deficient practice could affect staff only.

19. Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:36 p.m., the Executive Stairwell had a missing escutcheon. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

20. Based on observation and interview, the facility failed to provide sprinkler coverage for 1 of 1 East Entrance exterior canopies which was wider than 4 feet. NFPA 13, 2010 Edition, Section 8-15.7.2 states sprinklers shall be permitted to be omitted where the exterior roofs, canopies, balconies, decks or similar projections exceeding 4 feet in width are noncombustible, limited combustible or fire retardant-treated wood as defined in NFPA 703, Standard for Fire Retardant-Treated Wood and Fire-Retardant Coatings for Building Materials. This deficient practice could affect staff only.
21. Based on observation with the Maintenance Technician #1 on 12/07/16 at 9:04 a.m., a canopy of canvas construction over a metal frame outside of the main entrance was not provided with sprinkler protection. The canopy was attached to the building and extended over 4 feet from the building. Based on interview at the time of observation, the Maintenance Technician #1 confirmed no documentation was available for review to verify the canopy material was inherently flame retardant and was not provided with sprinkler protection.

22. Based on observation with the Maintenance Technician #1 on 12/06/16 at 2:56 p.m. then again on 12/07/16 at 8:31 a.m., the Boiler room fire extinguisher was sitting on the floor unprotected. Then again, the Kitchen K type fire extinguisher was sitting on the floor unprotected. Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

23. Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 4:28 p.m., the Recovery Administrative office has a turnstile built into the corridor. The turnstile has quarter inch multiple gaps in between the parts. Furthermore, LSC 19.3.6.1(7) was not met because the room was not protected by an electrically supervised automatic smoke detection system. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

24. Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/07/16 at 4:47 p.m., a one inch by two inch corridor penetration outside of the Director of Inpatient Care office. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

25. Based on observation with the Maintenance Technician #1 on 12/06/16 between 3:10 p.m. and 4:41 p.m., the following corridor doors were discovered:
a) two separate supply closets across from resident room 112 had one door latching into another. Both sets of doors contained one door with manual latching hardware and neither door positively latched into the frame.
b) a quarter inch door penetration around the door handle in the Housekeeping closet door
c) a quarter inch door penetration around the door handle in the staff bathroom
d) the Kitchenette double doors contained manual latching hardware and neither door positively latched into the frame. A single Kitchenette door left an eight inch gap when closed.
e) a door stop was on the Cafe Dining room door
f) a door stop was in the Nurses' station medication room
g) a door stop in the Director of Inpatient Care office
Based on observation with the Maintenance Technician #1 on 12/06/16 between 8:42 a.m. and 8:47 a.m., the following corridor doors were discovered:
h) a half inch penetration in the Financial office door
i) four separate quarter inch penetrations in the Group room 1 door
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

26. Based on record review with the Director of Facilities Management on 12/07/16 between 9:04 a.m. and 10:21 a.m., no documentation was available for the annual testing of the Kitchen's rolling fire door. Based on interview, the Director of Facilities Management acknowledged the aforementioned condition and confirmed no documentation was available for review.
27. Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 2:57 p.m. then again at 4:47 p.m., the North elevator equipment room contained 1 sprinkler head and no smoke or heat detector. Then again, the South elevator equipment room contained 1 sprinkler head. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management was unable to confirm the elevator equipment was provided with an elevator shunt trip.

28. Based on record review of the "Fire and Disaster Drill Report" form with the Director of Facilities Management on 12/06/16 at 10:16 a.m., there was no documentation for any third shift fire drills. Based on interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

29. Based on record review and interview, the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters. This deficient practice could affect all occupants.

30. Based on record review of titled "Fire and Disaster Drill Report" with the Director of Facilities Management on 12/06/16 at 10:16 a.m., the documentation for the drills for the past twelve months lacked verification of the transmission of the signal for drills. Based on interview at the time of record review, the Director of Facilities Management confirmed no documentation was available showing the times when the monitoring company received the fire alarm signal.

31. Based on observation with the Maintenance Technician #1 on 12/07/16 at 9:04 a.m., the East Entrance Overhang is constructed of a cloth material secured to the facility. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition and was unable to provide documentation showing the East Entrance Overhang NFPA 701 certification.

32. Based on observation with the Maintenance Technician #1 on 12/07/16 at 10:21 a.m., a candle with a wick was discovered in the Financial office. Based on interview at the time of observation, the Maintenance Technician #1 acknowledged the aforementioned condition.

33. Based on observation with the Maintenance Technician #1 on 12/06/16 between 2:14 p.m. and 4:28 p.m., the following was discovered:
a) twenty separate space heaters in Housekeeping Storage
b) a space heater in the Exam room
c) a space heater in the Recovery Administrator office
Based on observation with the Maintenance Technician #1 on 12/07/16 between 8:32 a.m. and 8:56 a.m., the following was discovered:
d) a space heater in the Director of Community Support Services office
e) a space heater in the Receptionist area
Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition and was unable to provide documentation confirming the space heaters heating element do not exceed 212 degrees.

34. Based on observation with the Maintenance Technician #1 on 12/06/16 between 2:02 p.m. and 3:40 p.m., the following was discovered:
a) an extension cord was powering a fan in the Marketing office
b) an extension cord was powering a fan in Office room 256
c) an extension cord was powering a calculator in the Accounting Storage room
d) an extension cord was powering a fan in the Experiential Therapy office
e) an extension cord was powering a calculator in the Accounting office. Additionally, a surge protector was powering two separate surge protectors powering computer components.
f) an extension cord was powering a compressor bladder in the Boiler room
g) an extension cord was powering a refrigerator in the Kitchenette
h) a surge protector was powering a refrigerator in the Therapist office
Based on observation with the Maintenance Technician #1 on 12/07/16 between 8:31 a.m. and 8:51 a.m., the following was discovered:
i) a surge protector was powering a microwave, toaster, and blender in the Kitchen
j) a surge protector was powering a microwave in Group room 3
k) a surge protector was powering another surge protector powering television equipment in the IT room
l) an extension cord was powering a white noise machine in the Clinical Coordinator's office

35. Based on interview at the time of each observation, the Maintenance Technician #1 acknowledged each aforementioned condition.

36. Based on observation and interview, the facility failed to ensure 1 of 1 Staff Bathroom was provided with a ground fault circuit interrupter (GFCI) protection against electric shock. LSC sections 9.1.2 requires all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, in 210.8(A), Dwelling Units, requires ground-fault circuit-interrupter (GFCI) protection for all personnel in bathrooms and kitchens where the receptacles are intended to serve the countertop surfaces. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect staff only.

37. Based on observation with the Maintenance Technician #1 and the Director of Facilities Management on 12/06/16 at 3:28 p.m., the Staff Bathroom had one receptacle within inches of the toilet bowl. When the GFCI tester button was pressed, power was not interrupted. Based on interview at the time of observation, the Maintenance Technician #1 and the Director of Facilities Management acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure emergency lighting was provided for 8 of 8 exits. LSC 7.9.1.1 Emergency lighting for the means of egress shall be provided.

Finding include:

Based on observation with the Maintenance Technician #1 on 12/06/16 at 3:42 p.m., there were exit lights on the exit discharge. Based on interview at the time of observation, the Maintenance Technician #1 was unable to confirm that the exterior lights were on the generator, but did confirm that there were not batteries in the exterior lights.

2. Based on record review and interview; the facility failed to ensure an undetermined number of battery operated emergency lights in the facility was maintained for 12 of 12 months in accordance with LSC 7.9. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment, requires a functional test to be conducted for 30 seconds at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than a 1 ½ hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

3. Based on record review with the Maintenance Technician #1 on 12/06/16 at 11:01 a.m., the battery operated emergency light documentation had check boxes on the fire drill forms. Additionally, no annual ninety minute test documentation was available for review. Based on interview at the time of observation, the Director of Facilities Management confirmed that the lights were just pressed for a couple of seconds to indicate that the light will turn on.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6 and failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
and failed to provide a 1 of 1 written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow.

Findings include:

1. Based on record review with the Director of Facilities Management on 12/06/16 at 10:43 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the insurance company and the person conducting the fire watch shall be trained and have no other duties while performing the fire watch. Additionally, the fire watch plan indicates "if the system is down for a time period greater than 24 hours, the Indiana State Department of Health will be contacted due to an "Unusual Occurrence" instead of contacting ISDH after four hours in a twenty four hour period. Based on an interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition

2. Based on a record review and interview on 12/07/16 at 3:51 p.m., the Maintenance Technician #1 and the Director of Facilities Management acknowledged the "Disaster Plan" did not address (9) Extinguishment of fire. The plan indicated to staff to use a fire extinguisher, but failed to indicate how to use a fire extinguisher.

3. Based on record review with the Director of Facilities Management on 12/06/16 at 10:43 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the insurance company and the person conducting the fire watch shall be trained and have no other duties while performing the fire watch. Additionally, the fire watch plan indicates "if the system is down for a time period greater than 24 hours, the Indiana State Department of Health will be contacted due to an "Unusual Occurrence" instead of contacting ISDH after four hours in a twenty four hour period. Based on an interview at the time of record review, the Director of Facilities Management acknowledged the aforementioned condition.

Based on document review and interview, the facility failed to ensure supplies and equipment were maintained at an acceptable level of safety related to availability of blunt utility scissors for 1 unit in one instance; and preventive maintenance for 3 of 3 pieces of equipment.

Findings:

1. Policy #5.18 titled, "Strangulation Intervention" revised/reapproved 12/13, indicated on pg. 1, under Procedure section, point 4., "Utility scissors are to be kept in the nursing station medicine cart or cabinet and are immediately brought to the scene."

2. Review of Incident Reports on 12/5/16 at approximately 1300 hours, indicated:
A. patient N2 attempted suicide by hanging on 9/20/16 at 1100 hours when staff walked into patient's room and found him/her standing on the shelf in their clothes wardrobe with a piece of bed sheet ripped and tied through a hole in the upper corner of the wardrobe and the other end of the bed sheet wrapped around his/her neck. When the client saw staff approaching, he/she buckled his/her knees in an attempt to hang himself/herself. Staff rushed to client and proceeded to lift the client up to keep him/her from choking. Other staff arrived immediately and cut the bed sheet to let the client down.
B. Inpatient Progress Note dated 9/20/16 indicated client was assessed by the Nurse Practitioner and found to have a small red dot on his/her neck where the skin was nicked while cutting the sheet.

3. Staff 2 (Director Inpatient Care Center [ICC]) was interviewed on 12/5/16 at approximately 1320 hours and confirmed, blunt utility scissors were not available for use on the ICC as required by facility policy and procedure and sharp scissors were used nicking the patient's neck.

4. While on tour of the facility on 12/7/16 and 12/8/16 at approximately 1130 and 1221 hours, in the company of staff 2 (Director ICC), the following was observed in the:
A. Patient Exam Room:
(1). freezer inside the refrigerator was iced up with a large block of ice.
(2). no preventive maintenance had been completed on the examination table and the scale.

B. Medication Room: freezer inside the refrigerator was iced up with a large block of ice.

5. A policy related to cleaning/maintenance of refrigerators was requested, but not provided.

Based on document review and interview, the Nursing Supervisor failed to complete Essential Learning activities regarding infection control per facility policy and procedure for 1 of 15 (16) personnel files reviewed.

Findings:

1. Policy #1.01 titled, "Infection Control Overview," revised/reapproved 4/16 indicated, on pg. 1, under Procedure section, points 1.a.i.1., "Oversight: a. An outpatient and inpatient Infection Control Nurse will be named. i. They will be qualified for their positions via their valid Registered Nurses license and completion of Essential Learning activities regarding infection control. 1. The Inpatient Nursing Supervisor is designated the responsibility of infection control for the Inpatient Care Center by the Medical Director of the organization."

2. Review of personnel records on 12/5/16 and 12/6/16 at approximately 1354 and 0930 hours indicated staff 16 (Inpatient Nursing Supervisor) lacked designation in writing that they were appointed the Infection Control Nurse and lacked completion of Essential Learning activities in infection control.

3. Staff 16 (Inpatient Nursing Supervisor) was interviewed on 12/7/16 at approximately 1200 hours and confirmed, they were also working as the Infection Control Nurse, but had not been designated as such in writing and had not completed training in infection control.

Based on document review and interview, the infection control officer failed to ensure implementation of an employee health program to determine the immunization and/or communicable disease history related to TB, Rubella, Rubeola, Varicella, Hepatitis B and Influenza for 11 of 15 (L105, L106, L107, 7, 16, 21-25 and 27) personnel files reviewed; and lacked a respiratory protection program that includes respiratory fit testing; and lacked a system for controlling infections and communicable diseases of patients related to environmental services, housekeeping practices and storage of soiled and clean laundry in 1 of 4 (Inpatient Care Center [ICC]) areas toured.

Findings:

1. Policy titled, "Hepatitis B Vaccination", revised/reapproved 7/15 indicated, on pg. 1, under Policy section, "The Center will make the Hepatitis B vaccine and vaccination series available to all employees."

2. Policy #4.03 titled, "Mycobacterium Tuberculosis Skin Testing (TST) of Staff", revised/reapproved 1/16 indicated, on pg. 1, under Policy and Procedure sections, point 1.b., "Currently annual screening is required for Inpatient Care Center staff...A test must be read no sooner than 48 hours from administration and no later than 72 hours after administration."

3. Policy titled, "Employee Tuberculosis Screening," revised/reapproved 3/15 indicated, on pg. 1, under Exemption section, "Employees who have two (2) annual chest x-rays on file with Human Resources will be screened for signs and symptoms of TB."

4. Policy titled, "Immunization Policy," revised/reapproved 7/16 indicated, on pg. 1, under Purpose and Policy sections, "to protect the health and safety of patients, employees, patient and employee family members, and the community as a whole by providing a consistent testing and immunization standard...staff with patient contact, will be required to receive or show record of having received the following immunizations: Influenza (mandatory annually by October 31st); Measles, Mumps and Rubella (MMR); Tdap; and Hepatitis B. Optional are: Varicella and Meningococcal...Newly hired employees will need to obtain immunization or present proof of immunization within 7 days of their start date. Existing staff may be required to submit to testing for titers of prior immunizations."

5. Policy #1.01 titled, "Infection Control Overview," revised/reapproved 4/16 indicated, on pg. 1, under Duties section, point 2.a.(vii)., "The Infection Control Nurses are responsible for identifying, controlling and preventing outbreaks of infection via the following: Monitoring documentation of health status."

6. Policy #1.02 titled, "Infection Control Plan", revised/reapproved 12/15 indicated, on pgs. 2 and 3, under Procedure section, points 1.d.1.c. and 2.c. "Airborne Precautions: Intended to prevent transmission of infectious organisms that are present in the air and remain contagious over long distances...M. tuberculosis...Interventions include but are not limited to...Use of N95 respirator. Must be fit tested upon initial hire and annually."

7. Review of CDC (Centers for Disease Control and Prevention) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, indicated on pg. 10, "All HCWs (Health Care Workers) should receive baseline TB screening upon hire, using two-step TST or a single BAMT (Blood Assay for Mycobacterium Tuberculosis) to test for infection with M. tuberculosis."

8. Review of personnel records on 12/5/16 and 12/6/16 at approximately 1354 and 0930 hours indicated:
A. Staff L105 (Housekeeper), hire date 10/16/2013 signed a consent to participate in the "Hepatitis B Immunization Program" on 10/23/13. There was no documentation the vaccination was made available to the staff member. The last TST documented for Housekeeper #L105 was administered on 1/14/15 at 1000 hours and read on 1/26/15 at 1200 hours, which is 12 days after it was administered.
B. Staff L106 (Housekeeper), hire date 8/21/14, had a chest x-ray performed on 11/15/2014. There was no other documentation of a chest x-ray, TST, or annual screening for signs and symptoms of tuberculosis.
C. Staff L107 (Social Worker), hire date 3/15/2007, last TST was administered on 5/11/12. There was no documentation of annual TST testing after that date.
D. Staff 7 (Registered Nurse [RN]), hire date 3/15/07, lacked documentation of TST, Rubella, Rubeola, Varicella, Hepatitis B and Influenza.
E. Staff 16, (RN), hire date 10/20/09, lacked documentation of TST, Rubella, Rubeola, Varicella, Hepatitis B and Influenza.
F. Staff 21, (RN), hire date 4/11/16, lacked documentation of Rubella, Rubeola, Varicella and Influenza.
G. Staff 22, (RN), hire date 1/4/16, lacked documentation of Rubella, Rubeola, Varicella and Influenza.
H. Staff 23, (RN), hire date 2/15/16, lacked documentation of Varicella and Influenza.
I. Staff 24, (Psych Tech [PT), hire date 11/9/15, lacked documentation of Rubella, Rubeola, Varicella and Influenza.
J. Staff 25, (PT), hire date 3/7/16, lacked documentation of Rubella, Rubeola, Varicella and Influenza.
K. Staff 27 (PT), hire date 10/15/15, lacked documentation of TST, Rubella, Rubeola, Varicella and Influenza.
L. All staff reviewed lacked N95 respirator fit testing upon initial hire and annually.

10. Staff 12 (Dietitian) was interviewed on 12/6/16 at approximately 1524 hours and confirmed, the hepatitis vaccination was not provided for staff L105. The TST for staff L105 was read late, there was no annual screening after the chest x-ray dated 11/15/14 for staff L106 and there was no current TST for staff L107.

11. Staff 16 (Inpatient Nursing Supervisor and Infection Control Preventionist) was interviewed on 12/7/16 at approximately 1200 hours and confirmed, the above-mentioned personnel were lacking proof of communicable disease history and/or immunization status as required per facility policy and procedure. The Infection Control Program follows CDC guidelines for TB, Rubella, Rubeola, Varicella, Hepatitis B and Influenza and these vaccines and/or documentation of immunizations are recommended by CDC for health care workers. Also, a respiratory protection program is being created, but all staff lack N95 respirator fit testing upon initial hire and annually.

12. Policy #1.01 titled, "Infection Control Overview," revised/reapproved 4/16 indicated, on pg. 1, under Oversight section, point 2.b., "The Director of Facilities is responsible for control and management of infectious waste or biohazard waste materials and appropriate cleaning procedures throughout the organization."

13. Policy #9.05 titled, "Linen Policy," revised/reapproved 12/13 indicated, on pg. 1, under Purpose and Procedure sections, points 1.b. and 2.c., "To implement an effective, sanitary procedure for the handling and storage of clean and soiled linen...1. Clean Linen: b. Assigned techs will store clean linen on designated shelves in clean linen room. 2. Soiled Linen: c. Assigned staff will be responsible for loading filled laundry bags onto the laundry cart, which is stored in the room designated for soiled linen."

14. Policy titled, "Daily Cleaning," revised/reapproved 11/16 indicated, on pg. 1, under Policy and Purpose sections, "Cleaning of all areas shall be completed daily. To provide a safe, clean, attractive, and secure environment for clients, visitors, and staff.

15. Policy titled, "Cleaning Supplies," revised/reapproved 1/14 indicated, on pg. 1, under Procedure section, points 1.a., "The following is the main list of disinfectant supplies used for cleaning...BETCO: dilution is 2 ounces per gallon of water." Odoban is not listed as a supply to be used (see #16 below).

16. Review of labels indicated:
A. BETCO pH7Q dilution is 2 ounces per gallon of water;
B. OdoBan dilution is 5 ounces per gallon of water.

17. While on tour of the facility on 12/8/16 at approximately 1221 hours, in the company of staff 2 (Director ICC), the following was observed:
A. staff 21 (Housekeeper) was doing a daily clean of patient's room and:
(1). did not provide clean bed linens, wash cloths or towels;
(2). did not wash the upper 2 foot portion of the shower walls.
B. soiled and clean linen were stored in the laundry room.

18. Staff 21 (Housekeeper) was interviewed on 12/8/16 at approximately 1320 hours, and confirmed clean bed linens, wash cloths or towels are not provided daily; the upper 2 foot portion of the shower walls are not cleaned because they cannot be reached; the high dusting tool has not been cleaned/changed for at least 10 months and is used from patient room to patient room; and the toilet cleaning brush is not cleaned/disinfected between uses and is used from patient room to patient room. Also, cleaning solutions and water are not measured according to manufacturer instructions when preparing.

19. Staff 2 (Director ICC) was interviewed on 12/8/16 at approximately 1645 hours, and confirmed soiled and clean linen are stored in the laundry room together and not stored as specified in facility policy and procedure, as clean linen in a clean linen room and soiled linen in a room designated for soiled linen.

Based on document review and interview, the facility failed to ensure that patient care was directed by a psychiatrist for one (1) of one (1) discharged patients. This deficiency results in patient assessment and treatment not being directed by a psychiatrist.

Findings include:

Patient 31

A. Record review

1. Patient 31 was admitted 11/2/16 at 12:40 a.m. The Nursing Assessment dated 11/20/16 at 1:40 a.m. stated that the Patient 31's sister had reported that "the patient was hallucinating and threatening to jump out [of] the moving car and also threatening to take all of her medications in an attempt to commit suicide." The Nursing Assessment stated "Patient did admit to still having suicidal thoughts . . ." and "Admission Criteria Met: Current active suicidal ideation . . ." The Nursing Assessment stated "Dangerousness: Suicidal Intent . . . Suicidal Ideation." Patient 31 was described as "Agitated, Irritable, Confused, Anxious" with "Disorganized thinking," "Auditory Hallucinations," "Confused," and with "Difficulty Intergrating [sic] Thoughts." The goal of treatment included "Decrease in suicidal thoughts."

2. The nursing progress note on 11/2/16 at 9:18 a.m. stated "Client was found kneeling at the side of the toilet. Client had taken a patient gown and had knotted it around her neck. Client was found leaning forward and did not appear to be breathing. . . No carotid or radial pulse noted. . . 911 called by assisting staff. CPR initiated . . . Client remained unresponsive throughout CPR procedure. . . Client transported to [local medical facility] Emergency Room."

3. The physician order dated 11/2/16 at 11:50 a.m. stated "Discharge Pt [patient] as Pt was admitted to [local medical facility]."

4. The commitment document, "Report Following Emergency Detention" dated 11/4/16 stated "Pt came from [the facility] - intubated and on a mechanical ventilator. Sent to [university medical center in another city] for higher level of care." "At this time [s/he] is sedated post full arrest and helicopter flight to [university] med [medical] center. 11-13-16."

5. A review of the medical record indicated that the patient had only been assessed by nursing staff and no psychiatric evaluation or physical examination was completed during this hospitalization.

B. Staff Interview

During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he stated that Patient 31 had not been evaluated by a physician during this hospitalization and had not received a psychiatric assessment or physical examination during this hospitalization.

Based on observation, interview, and record review, the facility failed to:

I. Develop and document comprehensive Multidisciplinary Treatment Plans (MTP) based on individual patient needs. (Refer to B118)

II. Ensure that a physician assessed the suicide risk of patients at the time of admission for one (1) of one (1) discharged patients (31) so that an appropriate level of observation could be determined. This failure potentially results in the inadequate level of treatment and supervision being available for patients with suicide risk. (Refer to B125)

Based on record review and interview, the facility failed to provide social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions, and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (1, 2, 3, 4, 6, 7, 8, and 9). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions.

Findings include:

A. Record Review

The following Psychosocial Assessments (dates in parentheses) failed to include an evaluation of psychosocial issues, conclusions and recommendations, or a description of the social worker ' s role in treatment and discharge planning: Patient 1 (12/5/16), Patient 2 (12/4/16), Patient 3 (12/3/16), Patient 4 (11/28/16), Patient 6 (12/6/16), Patient 7 (12/5/16), Patient 8 (12/5/16) and Patient 9 (11/23/16).

B. Staff Interview

1. During an interview with SW 1 on 12/6/16 at 9:10 a.m., she acknowledged that these Psychosocial Assessments lacked an evaluation of the psychosocial issues, conclusions and recommendations, or a description of the social work role in treatment or discharge planning.

2. During an interview on 12/6/16 at 2:10 p.m., the Vice President of Clinical Services, who supervised social work services, acknowledged that these Psychosocial Assessments lacked an evaluation of the psychosocial issues, conclusions and recommendations, or a description of the social work role in treatment or discharge planning.

Based on record review and interview, ensure that a psychiatric evaluation was documented that contained sufficient information to justify psychiatric diagnoses and treatment for one (1) of eight (8) active sample patients (4) and that a completed psychiatric evaluation was completed for one (1) of one (1) discharged patients (31). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses.

Findings include:

A. Record review

1. Patient 4 was admitted on 11/23/16. The Psychiatric Evaluation dated 11/24/16 included diagnoses of "Bipolar I Disorder Current or Most Recent Episode Depressed, Severe with Psychotic Features" and "Alcohol Use Disorder, Moderate." The Psychiatric Evaluation did not contain the necessary information to justify these diagnoses and planned treatment.

2. Patient 31 was admitted on 11/2/16. No Psychiatric Evaluation was completed prior to discharge.

B. Staff Interviews

1. During an interview with MD 1 on 12/6/16 at 11:30 a.m., she acknowledged that the psychiatric evaluation for Patient 4 did not document sufficient information to justify the psychiatric diagnoses. She acknowledged that no psychiatric evaluation was completed for Patient 31 prior to discharge.

2. During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that the psychiatric evaluation for Patient 4 did not document sufficient information to justify the psychiatric diagnoses. He acknowledged that no psychiatric evaluation was completed for Patient 31 prior to discharge.

Based on record review and interview, the facility failed to ensure that the psychiatric evaluations of seven (7) of eight (8) active sample patients (2, 3, 4, 6, 7, 8, and 9) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient.

Findings include:

A. Record Review

The following Psychiatric Evaluations (dates in parentheses) failed to include specific patient assets that could be used in treatment planning: Patient 2 (12/4/16), Patient 3 (12/2/16), Patient 4 (11/24/16), Patient 6 (12/5/16), Patient 7 (12/4/16), Patient 8 (12/4/16), and Patient 9 (11/22/16).

B. Staff Interviews

1. During an interview with MD 1 on 12/6/16 at 11:30 a.m., she acknowledged that the psychiatric evaluations for Patients 2, 3, 4, 6, 7, 8, and 9 did not document patient assets to utilize in treatment planning.

2. During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that the psychiatric evaluations for Patients 2, 3, 4, 6, 7, 8, and 9 did not document patient assets to utilize in treatment planning.

Based on record review and interview, the facility failed to develop and document comprehensive Multidisciplinary Treatment Plans (MTP) based on individual patient needs. Specifically, the facility fai1ed to develop and document treatment plans that included:

A. Patient strengths (as well as disabilities) for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9). The MTPs incorrectly listed external resources, e.g., "supportive family," as patient strengths/assets and/or failed to specify how identified patient strengths/assets would be used to support the inpatient treatment. Failures to identify and incorporate patient strengths in the Master Treatment Plan diminish the effectiveness of treatment interventions, and can hamper the patient's achievement of treatment goals. (Refer to B119)

B. A substantiated diagnosis for three (3) of eight (8) active sample patients (1, 6 and 9). This failure results in an absence of active psychiatric treatment directed by the treatment plan. (Refer to B120)

C. Short-term goals (called objectives by this facility) that were stated in observable, measurable, and behavioral terms for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment intervention, and may contribute to failure of the team to modify plan in response to patient needs. (Refer to B121)

D. Active treatment interventions with a specific focus. Interventions were either generic monitoring or discipline function to be performed by physician, nurses, and social work. The interventions did not include frequency and duration. These deficiencies resulted in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific intervention and the purpose for each. These failures will potentially result in inconsistent and/or ineffective treatment resulting in prolonged patient stay. interventions. (Refer to B122)

Based on policy review, record review, and interview, the facility failed to provide Master Treatment Plans (MTPs) that were based on patient strengths (as well as disabilities) for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9). The MTPs incorrectly listed external resources, e.g., "supportive family," as patient strengths/assets and/or failed to specify how identified patient strengths/assets would be used to support the inpatient treatment. Failures to identify and incorporate patient strengths in the Master Treatment Plan diminish the effectiveness of treatment interventions, and can hamper the patient's achievement of treatment goals.

Findings include:

A. Policy Review:

The facility policy, "Inpatient Treatment Plan" reviewed 11/13, include the following statements: First page (pages not numbered). "Policy": "Each patient must have an individual comprehensive treatment plan that must be based on an inventory of the patient's strengths and disabilities."

B. Record Review:

1. Patient 1 (MTP dated 12/3/16) identified the following strengths: "Creative, empathic listener, supportive family." There was no evidence on the MTP how the identified strengths and/or disabilities were to be used to support the patient's treatment goal(s).

2. Patient 2 (MTP dated 12/1/16) identified no strengths and/or disabilities. "Unable to assess).

3. Patient 3 (MTP dated 12/1/16) identified the following strength: "Supportive husband and family." There was no evidence on the MTP how the identified strengths and/or disabilities were to be used to support the patient's treatment goal(s).

4. Patient 4 (MTP dated 11/24/16) identified the following strengths: "Supportive family, responds to directions cooperatively." There was no evidence on the MTP how the identified strengths and/or disabilities were to be used to support the patient's treatment goal(s).

5. Patient 6 (MTP dated 12/4/16) identified the following strengths: "Supportive family and friends, employed, attending college." There was no evidence on the MTP how the identified strengths and/or disabilities were to be used to support the patient's treatment goal(s).

6. Patient 7 (MTP dated 12/4/16) identified the following strengths: "Supportive father, cooperative, willing to seek outpatient treatment." There was no evidence on the MTP how the identified strengths and/or disabilities were to be used to support the patient's treatment goal(s).

7. Patient 8 (MTP dated 12/3/16) identified the following strengths: "Supportive sister, college educated, employed." There was no evidence on the MTP how the identified strengths and/or disabilities were to be used to support the patient's treatment goal(s).

8. Patient 9 (MTP dated 11/21/16) identified the following strength: "To be able to see son everyday." There was no evidence on the MTP how the identified strength and/or disability were to be used to support the patient's treatment goal(s).

C. Staff Interviews:

1. During an interview with RN I on 12/5/16 at 2:15 p.m., the RN 1 acknowledged, "It's just listed. We follow the SNAP (strength, needs, abilities, preference) format."

2. During an interview with MD 1 on 12/6/16 at 11:30 a.m., she acknowledged that the MTPs for Patients 1, 6, and 9 did not document strengths and disabilities.

3. During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that the MTPs for Patients 1, 6, and 9 did not document strengths and disabilities.

Based on record review and interview, the facility failed to develop Master Treatment Plans that included substantiated diagnosis for three (3) of eight (8) active sample patients (1, 6 and 9). This failure results in an absence of active psychiatric treatment directed by the treatment plan.

Findings include:

A. Record Review:

1. Patient 1: MTP dated 12/3/16 did not include a substantiated diagnosis.

2. Patient 6: MTP dated 12/4/16 did not include a substantiated diagnosis.

3. Patient 9: MTP dated 11/21/16 did not include a substantiated diagnosis.

B. Staff Interviews

1. During an interview with MD 1 on 12/6/16 at 11:30 a.m., she acknowledged that the MTPs for Patients 1, 6, and 9 did not document diagnoses.

2. During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that the MTPs for Patients 1, 6, and 9 did not document diagnoses.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPs) which consistently include short-term goals (called objectives by this facility) that were stated in observable, measurable, and behavioral terms for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment intervention, and may contribute to failure of the team to modify plan in response to patient needs.

Findings include:

A. Record Review

The MTPs for the following active sample patients were examined (dates of plans in parenthesis): Patient 1 (12/3/16), Patient 2 (12/1/16), Patient 3 (12/1/16), Patient 4 (11/24/160, Patient 6 (12/4/16) Patient 7 (12/4/16), Patient 8 (12/3/16) and Patient 9 (11/21/16). Active sample patients 1, 6, 7 and 8 goals were identical and active sample patients 2, 3 and 4 goals were identical. Examination of the MTPs revealed no short-term goals were identified for 8 of 8 active sample patients (1, 2, 3, 4, 6, 7, 8 and 9).

1. Patient 1

Psychiatric evaluation dated 12/4/16 indicated patient reported "[patient] had been having increased thoughts of suicide for the past few weeks." "An overwhelming thought of not being here." Patient describes low energy, low motivation, lack of participation in things [patient] used to like." Objectives for patient were: "Client will be able to contract for safety, client will verbalize intent to maintain safe behavior." There was no indication if objectives were long-term or short-term.

2. Patient 2

Psychiatric evaluation dated 12/2/16 indicated patient "was confused and making statements [patient] wants to die." Objectives for patient were: "Client will reduce psychotic symptoms, client will maintain mood stability." There was no indication if objectives were long-term or short-term.

3. Patient 3

Psychiatric evaluation dated 12/1/16 indicated "Patient was mumbling, disorganized, restless, confused." Objective for patient was: "Client will reduce psychotic symptoms."
There was no indication if objectives were long-term or short-term.

4. Patient 4

Psychiatric evaluation dated 11/24/16 indicated "Patient has was been thinking that [patient's] mother wants to kill [patient]." "Tearful, sad crying." Objective for patient was: "Client will reduce psychotic symptoms." There was no indication if objective was long-term or short-term.

5. Patient 6

Psychiatric evaluation dated 12/5/16 indicated, "Patient threatened to kill [patient's] self." "Felt suicidal because [patient] was angry." "I cut myself to get rid of emotional pain." "Feeling depressed for the past many years." Objectives for patient were: "Client will be able to contract for safety, client will verbalize intent to maintain safe behavior." There was no indication if objectives were long-term or short-term.

6. Patient 7

Psychiatric evaluation dated 12/4/16 indicated "Patient threatened to kill self, put a gun to my head and pulled the trigger and it didn't fire." "Feels down all the time." "I was going to jump off a bridge a few weeks ago." Objectives for patient were: "Client will be able to contract for safety, client will verbalize intent to maintain safe behavior." There was no indication if objectives were long-term or short-term.

7. Patient 8

Psychiatric evaluation dated 12/4/16 indicated "Patient took an overdose of [patient's] opioid medication in an attempt to kill self." "Made comments to sister of not wanting to be alive for the past several years." "I am unhappy." Objectives for patient were: "Client will be able to contract for safety, client will verbalize intent to maintain safe behavior." There was no indication if objectives were long-term or short-term.

8. Patient 9

Psychiatric evaluation dated 11/22/16 indicated "Patient was disorganized labile and delusional." Objectives for patient were: "Client will maintain mood stability, client will exhibit improved affect in increase participation in activities." There was no indication if objectives were long-term or short-term.

B. Staff Interviews

1. During an interview with the Nursing Director and RN 1 on 12/6/16 at 1:30 p.m., the DON agreed that the "Treatment Plans" (MTPs) goals were not written in observable, measurable, and behavioral terms. She stated, " We are aware and working on it, we need to be more on target." The RN I acknowledge that the treatment plans needed to be improved.

2. During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that the MTPs for Patients 1, 2, 3, 4, 6, 7, 8, and 9 did not document treatment goals stated in observable, measurable, behavioral terms written in observable, measurable, behavioral terms.

Based on record review and interview, the facility failed to develop Master Treatment Plans (MTPS) for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9), that included active treatment interventions with a specific focus. Interventions were either generic monitoring or discipline function to be performed by physician, nurses, and social work. The interventions did not include frequency and duration. These deficiencies resulted in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific intervention and the purpose for each. These failures will potentially result in inconsistent and/or ineffective treatment resulting in prolonged patient stay.

Findings include:

A. Record Review (date of MTP in parentheses)

The MTPs for the following patients were reviewed (dates of plans in parentheses): Patient 1 (12/3/16), Patient 2 (12/1/16), Patient 3 (12/1/16), Patient 4 (11/24/16), Patient 6 (12/4/16), Patient 7 (12/4/16), Patient 8 (12/3/16) and Patient 9 (11/21/16). The treatment plans contained the following routine and generic discipline functions written as interventions instead of individualized specific interventions to assist patients to accomplish treatment goals. Several statements, written as interventions, were identical or similarly worded despite different presenting symptoms and needs of each patient.

1. Patient 1

a. For the problem of "Suicidal Ideation," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral, per client request," and
"Education about risk and benefits of medications and treatments."

Nursing: "Administer meds as ordered," "Assess for continued risk for self harm," "Encourage patient expression of feelings," "Encourage patient to attend unit groups," "Patient teaching coping skills," "Reinforce patient for using effective coping skills," and
"Milieu Therapy."

Social work: "Family assessment, Within 60 hours of admission."

b. For the problem of "Drug problems," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Physician determined that the patient's withdrawal syndrome has been completed" and "Substance Abuse Services referral, prior to discharge."

Nursing: "Medication evaluation and/or management," "Monitor for Opioids withdrawal," "Monitor sleep patterns throughout the day and night," "Basic alcohol and drug education," "Assist client in concrete coping methods which will help reduce drug use," "Assist client in understanding relationship of alcohol or drug use patient symptoms," and "Discuss with patient effects of substance use has had on his/her own life."

Social work: No interventions identified.

2. Patient 2

For the problem of "Delusional Thoughts," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral, per client request," and "Education about risk and benefits of medications and treatments."

Nursing: "Administer meds as ordered" and "Monitor sleep patterns throughout the day and night."

Social work: "Assess thought processes throughout the shift," "Assess for mood lability throughout the shift," and "Encourage patient to attend unit groups," "Encourage patient expression of feelings," "Engage patient in structured, focused activities," "Note any evidence of patient responding to internal stimuli," "Patient teaching coping skills," "Re-direct patient ' s attention as necessary, " " Reinforce patient for using effective coping skills, " "Reorient/reinforce reality in a matter of fact way, as needed," "Use distraction activities to decrease worry and confusion," "Milieu Therapy," and "Family assessment, Within 60 hours of admission."

3. Patient 3

For the problem of "Thought Processes, Altered," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral," and "Education about risk and benefits of medications and treatments."

Nursing staff: "Administer meds as ordered," "Assess thought processes throughout the shift," "Encourage patient to attend unit groups," "Engage patient in structured, focused activities," "Note any evidence of patient responding to internal stimuli," "Patient teaching coping skills," "Reinforce patient for using effective coping skills," "Reorient/reinforce reality in a matter of fact way," "Teach patient skills to use to decrease distress from audio hallucinations," and "Milieu Therapy."

Social work: "Family assessment, Within 60 hours of admission."

4. Patient 4

For the problem of "Thought Processes, Altered," the MTP documented the identical routine and generic discipline interventions for the psychiatrist, nursing, and social work as for Patient 3's problem of "Thought Processes, Altered."

5. Patient 6

a. For the problem of "Suicidal Ideation," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," and "Outpatient psychopharmacology referral."

Nursing: "Administer meds as ordered," "Assess for continued risk for self harm," "Encourage patient expression of feelings," "Encourage patient to attend unit groups," "Patient teaching coping skills," "Reinforce patient for using effective coping skills," "Milieu Therapy," and "Education about risk and benefits of medication."

Social work: "Family assessment, Within 60 hours of admission."

b. For the problem of "alcohol problem," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: No interventions documented.

Nursing: "Medication evaluation and/or management," "Monitor for Alcohol withdrawal patient symptoms," "Monitor sleep patterns throughout the day and night," "Basic alcohol and drug education," "Assist client in understanding relationship of alcohol or drug use patient symptoms," "Discuss with patient effects of substance use has had on his/her own life," "Integration of patient into the treatment process," and "Insight negative consequences of substance on life's goals."

Social work: No interventions documented.

6. Patient 7

a. For the problem of "Suicidal Ideation," the MTP documented the only following routine and generic discipline functions:

Psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral," and "Education about risk and benefits of medications and treatments."

Nursing: "Administer meds as ordered," "Assess for continued risk for self harm," "Encourage patient expression of feelings," "Encourage patient to attend unit groups," "Patient teaching coping skills," "Reinforce patient for using effective coping skills," and "Milieu Therapy."

Social work: "Family assessment, Within 60 hours of admission."

b. For the problem of "Anger management," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Referral to anger management, as needed" and "Pharmacological Management."

Nursing: "Confront denial and projection of responsibility," "Differentiate between feelings and behavior," "Encourage client to see the problem that lies in her or her own behavior," "Intermediate awareness negative consequences," "Sensitively probe losses incurred by clients behavior," "Teach or otherwise identify alternative coping methods for anger," "Encourage patient expression of feelings," "Encourage patient to attend unit groups," "Reinforce maintaining control behavior," "Patient teaching coping skills," "Reinforce patient for using effective coping skills," and "Milieu Therapy."

Social work: No interventions documented.

7. Patient 8

For the problem of "Suicidal Ideation," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," and "Education about risk and benefits of medications and treatments."

Nursing: "Administer meds as ordered," "Assess for continued risk for self harm," "Encourage patient expression of feelings," "Encourage patient to attend unit groups," "Patient teaching coping skills," "Reinforce patient for using effective coping skills," "Outpatient psychopharmacology referral, per client request," and "Milieu Therapy."

Social work: "Family assessment, Within 60 hours of admission"

8. Patient 9

For the identified problem of "elevated mood and illogical thoughts," the MTP documented only the following routine and generic discipline functions:

Psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," and "Education about risk and benefits of medications and treatments."

Nursing: "Administer meds as ordered" and "Monitor sleep patterns throughout the day and night."

Social work: "Family assessment, Within 60 hours of admission," "Assess thought processes throughout shift," "Assess for mood lability throughout shift," "Encourage patient to attend unit groups," "Encourage patient expression of feelings," "Encourage patient in structured, focused activities," "Note any evidence of patient responding to internal stimuli," "Patient teaching coping skills," "Re-direct patient's attention as necessary," "Reinforce patient for using effective coping skills," "Reorient/reinforce reality in a matter of fact way," "Use distraction activities to decrease worry and confusion," and "Milieu Therapy."

B. Staff Interviews

1. During an interview with the Nursing Director and RN I on 12/6/16 at 1:30 p.m., the DON agreed that the "Treatment Plans" (MTPs) interventions were not written in observable, measurable, and behavioral terms. She stated, " We are aware and working on it, we need to be more on target." The RN I acknowledge that the treatment plans needed to be improved.

2. During an interview with MD 1 on 12/6/16 at 11:30 a.m., she acknowledged that the MTPs for Patients 1, 2, 3, 4, 6, 7, 8, and 9 did not document individualized interventions to be performed by the psychiatrist with a specific focus of treatment based on each patient's individual problems and goals.

3. During an interview with the Vice President of Clinical Services who supervised social work services, on 12/6/16 at 2:10 p.m., she acknowledged that the social work interventions on the MTP's were generic and not specific to patient needs of Patients 1, 2, 3, 4, 6, 7, 8, and 9).

4. During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that the MTPs for Patients 1, 2, 3, 4, 6, 7, 8, and 9 did not document individualized interventions to be performed by the psychiatrist with a specific focus of treatment based on each patient's individual problems and goals.

Based on record review and interview, the facility failed to ensure that a physician assessed the suicide risk of patients for one (1) of one (1) discharged patients (31) to determine an appropriate level of observation or if other precautions were indicated. This failure potentially results in the inadequate level of treatment and supervision being available for patients with suicide risk.

Patient 31

A. Record review

1. Patient 31 was admitted 11/2/16 at 12:40 a.m. The Nursing Assessment dated 11/20/16 at 1:40 a.m. stated that the Patient 31's sister had reported that "the patient was hallucinating and threatening to jump out [of] the moving car and also threatening to take all of her medications in an attempt to commit suicide." The Nursing Assessment stated "Patient did admit to still having suicidal thoughts . . ." and "Admission Criteria Met: Current active suicidal ideation . . ." The Nursing Assessment stated "Dangerousness: Suicidal Intent . . . Suicidal Ideation." Patient 31 was described as "Agitated, Irritable, Confused, Anxious" with "Disorganized thinking," "Auditory Hallucinations," "Confused," and with "Difficulty Intergrating [sic] Thoughts." The goal of treatment included "Decrease in suicidal thoughts."

2. The admission Physician's Orders dated 11/1/16 at 11:00 p.m. ordered that Patient 31 received "15 minute visual checks." No increased observation or suicide precautions were ordered.

3. The nursing progress note on 11/2/16 at 9:18 a.m. stated "Client was found kneeling at the side of the toilet. Client had taken a patient gown and had knotted it around her neck. Client was found leaning forward and did not appear to be breathing. . . No carotid or radial pulse noted. . . . 911 called by assisting staff. CPR initiated . . . Client remained unresponsive throughout CPR procedure. . . Client transported to [local medical facility] Emergency Room."

4. The physician order dated 11/2/16 at 11:50 a.m. stated "Discharge Pt [patient] as Pt was admitted to [local medical facility]."

5. The commitment document, "Report Following Emergency Detention" dated 11/4/16 stated "Pt came from [the facility] - intubated and on a mechanical ventilator. Sent to [university medical center in another city] for higher level of care." "At this time [s/he] is sedated post full arrest and helicopter flight to [university] med [medical] center. 11-13-16."

6. A review of the medical record indicated that Patient 31's risk for suicide had not been assessed by a physician during this hospitalization.

B. Staff Interview

During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that Patient 31 had not received a suicide assessment by a physician to determine an appropriate level of observation or if other precautions were indicated during this hospitalization.

Based on observations, interview and record review, it was determined that monitoring and evaluation by the Medical Director did not include sufficient review and corrective measures to assure compliance with necessary practices, treatment of patients, and documentation of treatment in the facility. The Medical Director failed to:

I. Ensure that a psychiatric evaluation was documented that contained sufficient information to justify psychiatric diagnoses and treatment for one (1) of eight (8) active sample patients (4) and that a completed psychiatric evaluation was completed for one (1) of one (1) discharged patients (31). This failure results in a lack of patient information necessary for the treatment team to formulate an appropriate Master Treatment Plan for the treatment psychiatric illnesses. (Refer to B110)

II. Ensure that the psychiatric evaluations of sevent (7) of eight (8) active sample patients (2, 3, 4, 6, 7, 8, and 9) included an inventory of specific patient assets that could be used in treatment planning. Failure to identify patient assets impairs the treatment team's ability to develop interventions, utilizing the individual strengths of each patient. (Refer to B117)

III. Develop and document comprehensive Multidisciplinary Treatment Plans (MTP) based on individual patient needs. (Refer to B118)



IV. Provide Master Treatment Plans (MTPs) that were based on patient strengths (as well as disabilities) for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9). The MTPs incorrectly listed external resources, e.g., "supportive family," as patient strengths/assets and/or failed to specify how identified patient strengths/assets would be used to support the inpatient treatment. Failures to identify and incorporate patient strengths in the Master Treatment Plan diminish the effectiveness of treatment interventions, and can hamper the patient's achievement of treatment goals. (Refer to B119)

V. Provide Master Treatment Plans (MTPs) that included substantiated diagnosis for three (3) of eight (8) active sample patients (1, 6 and 9). This failure results in an absence of active psychiatric treatment directed by the treatment plan. (Refer to B120)

VI. Develop Master Treatment Plans (MTPs) which consistently include short-term goals (called objectives by this facility) that were stated in observable, measurable, and behavioral terms for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9). This failure hinders the ability of the treatment team to measure change in the patient as a result of treatment intervention, and may contribute to failure of the team to modify plan in response to patient needs. (Refer to B121)

VII. Develop Master Treatment Plans (MTPS) for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9), that included Active treatment interventions with a specific focus. Interventions were either generic monitoring or discipline function to be performed by physician, nurses, and social work. The interventions did not include frequency and duration. These deficiencies resulted in treatment plans that failed to reflect an individualized approach to multidisciplinary treatment and failed to provide guidance to staff regarding the specific intervention and the purpose for each. These failures will potentially result in inconsistent and/or ineffective treatment resulting in prolonged patient stay.

A. Record Review (date of MTP in parentheses)

1. Patient 1 (12/3/16)

a. For the problem of "Suicidal Ideation," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral, per client request," and "Education about risk and benefits of medications and treatments."


b. For the problem of "Drug problems," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Physician determined that the patient's withdrawal syndrome has been completed" and "Substance Abuse Services referral, prior to discharge."

2. Patient 2 (12/1/16)

For the problem of "Delusional Thoughts," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral, per client request," and "Education about risk and benefits of medications and treatments."

3. Patient 3 (12/1/16)

For the problem of "Thought Processes, Altered," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral," and "Education about risk and benefits of medications and treatments."

4. Patient 4 (11/24/16)

For the problem of "Thought Processes, Altered," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral," and "Education about risk and benefits of medications and treatments."

5. Patient 6 (12/4/16)

a. For the problem of "Suicidal Ideation," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," and "Outpatient psychopharmacology referral."

b. For the problem of "alcohol problem," the MTP documented no interventions to be performed by the psychiatrist.

6. Patient 7 (12/4/16)

a. For the problem of "Suicidal Ideation," the MTP documented the only following routine and generic discipline functions for the psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Outpatient Psychopharmacology referral," and "Education about risk and benefits of medications and treatments."

b. For the problem of "Anger management," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Referral to anger management, as needed" and "Pharmacological Management."

7. Patient 8 (12/3/16)

For the problem of "Suicidal Ideation," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Pharmacological Management,
Psychiatric Evaluation, within 24 hours of admission," "Outpatient psychopharmacology referral, per client request," and "Education about risk and benefits of medications and treatments."

8. Patient 9 (11/21/16)

For the identified problem of "Mood Instability," the MTP documented only the following routine and generic discipline functions for the psychiatrist: "Pharmacological Management," "Psychiatric Evaluation, within 24 hours of admission," "Education about risk and benefits of medications and treatments," and "Outpatient psychopharmacology referral, per client request."

B. Staff Interviews

1. During an interview with MD 1 on 12/6/16 at 11:30 a.m., she acknowledged that the MTPs for Patients 1, 2, 3, 4, 6, 7, 8, and 9 did not document individualized interventions to be performed by the psychiatrist with a specific focus of treatment based on each patient's individual problems and goals.

2. During an interview with the Medical Director on 12/6/16 at 8:15 a.m., he acknowledged that the MTPs for Patients 1, 2, 3, 4, 6, 7, 8, and 9 did not document individualized interventions to be performed by the psychiatrist with a specific focus of treatment based on each patient's individual problems and goals.

VIII. Ensure that a physician assessed the suicide risk of patients for one (1) of one (1) discharged patients (31) to determine an appropriate level of observation or if other precautions were indicated. This failure potentially results in the inadequate level of treatment and supervision being available for patients with suicide risk. (Refer to B125)

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

I. Ensure that active treatment interventions to be implemented by Registered Nurses were individualized and contained a specific purpose and/or focus based on needs for each eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9). This deficiency resulted in treatment plans that failed to reflect a comprehensive and individualized nursing approach to treatment. (Refer to B122).

II. Ensure the Master Treatment Plans (MTPs) for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8 and 9), identifying short-term/long-term treatment goals that were observable and measurable and addresses the individual patient presenting problems and needs. (Refer to B 121).

Interview:

During an interview with the Nursing Director and RN I on 12/6/16 at 1:30 p.m., the DON agreed that the "Treatment Plans" (MTPs) goals and interventions were not written in observable, measurable, and behavioral terms. She stated, "We are aware and working on it, we need to be more on target." The RN I acknowledge that the treatment plans needed to be improved.

Based on record review and staff interview, the Director of Social Work failed to:

I. Ensure that social work staff provided social work assessments that included a social evaluation of strength/deficits and high risk psychosocial issues, conclusions and recommendations of the anticipated necessary steps for discharge to occur, specific community resources/support systems for utilization in discharge planning, and the anticipated social work role in treatment and discharge planning for eight (8) of eight (8) sample patients (1, 2, 3, 4, 6, 7, 8, and 9). As a result, the treatment team did not have necessary social information and evaluation of social functioning level to utilize in developing treatment goals and interventions. (Refer to B108)

II. Ensure that social work interventions on treatment plans stated specific treatment modalities with a frequency of contact and a specific focus or purpose of treatment based on each patient's individual problems and goals for eight (8) of eight (8) active sample patients (1, 2, 3, 4, 6, 7, 8, 9). Instead, MTPs included identical routine social work discipline functions and/or generic vague and global statements of a treatment focus written as treatment interventions. These deficiencies result in a failure to guide treatment staff regarding the specific treatment modality and purpose for each intervention, potentially resulting in inconsistent and/or ineffective treatment.

Findings include:

A. Record Review (MTP dates in parenthesis)

The MTPs for the following patients (date of MTP in parenthesis) documented only the generic disciple function of "Family assessment, Within 60 hours of admission" for all identified problems: Patient 1 (12/3/16), Patient 2 (12/1/16), Patient 3 (12/1/16), Patient 4 (11/24/16), Patient 6 (12/4/16), Patient 7 (12/4/16), Patient 8 (12/3/16), Patient 9 (11/21/16).

B. Staff Interviews

1. During an interview with SW 1 on 12/6/16 at 9:10 a.m., she acknowledged that the social work interventions on the MTP's were generic and not specific to patient needs of Patients 1, 2, 3, 4, 6, 7, 8, and 9).

2. During an interview on 12/6/16 at 2:10 p.m., the Vice President of Clinical Services, who supervised social work services, acknowledged that the social work interventions on the MTP's were generic and not specific to patient needs of Patients 1, 2, 3, 4, 6, 7, 8, and 9.