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Based on review of hospital documents, direct observations, policies, procedures, video surveillance, and staff interviews, it was determined the Governing Body failed to ensure deficient practices identified during a root cause analysis (RCA) were effectively corrected as evidenced by failing to:

A0263: require Quality Assurance Performance Improvement (QAPI) maintained an effective, data driven program as demonstrated by failing to require:

A0267: QAPI activities identified and analyzed unanticipated outcome events and implemented effective corrective actions identified during a RCA conducted after the death of Pt #3 and failing to correct an immediate jeopardy deficient practice identified on 09/09/11 and 09/13/11;

A0392: have adequate numbers of personnel available to meet the needs of 3 patients on the Hopi unit who were sleeping on mattresses, on the floor, in the hallway, during the night at 0330 hours on 09/16/11, with one behavioral health technician (BHT) responsible for monitoring the 3 patients (Pts #31, 32, and 33);

A0395: require a registered nurse supervised and evaluated the nursing services, as evidenced by:

a. the RN failed to require 7 of 7 patients on the Adobe Unit had every 15 minute intensive observation monitoring (Pt #'s 3, 21, 22, 23, 24, 25, and 26), with Pt #3 found unresponsive and stiff;

b. the RN failed to require 18 patients on the Adobe Unit on 09/10/11 at 0300 through 0339 hours, had adequate every 15 minute rounds and/or every 30 minute rounds as ordered by the physicians (Pts #27, 28, 29, and 30 required every 15 and 30 minute rounding);

A404: require nursing documented medications administered to Pt #3 who was found dead approximately 17 hours after admission to the hospital; and

A405: require the Methadone Usage Policy was implemented for patient safety for 3 of 4 patients (Pts #3, 18 and 19).

The cumulative effect of these systemic deficient practices resulted in the Hospital's failure to meet the requirements for the Condition of Participation for Governing Body.

Based on observations during tour, review of hospital policies/procedures, medical records, hospital documents, and staff interviews, it was determined the hospital failed to require Quality Assurance Performance Improvement (QAPI) maintained an effective, data driven program as demonstrated by failing to require:

A0267: activities were identified and unanticipated outcome events analyzed with effective corrective actions implemented following a root cause analysis (RCA) conducted after the death of Pt #3 9/2010; the same deficient practice resulting in an immediate jeopardy citation was identified on 09/09/11 and remained uncorrected 09/13/11; and failing to evaluate the services provided to 1 of 1 patients in an emergency situation (Pt #34).

The cumulative effect of this continued systemic deficient practice resulted in the Hospital's failure to meet the requirements for the Condition of Participation for QAPI.

Based on observations during tour, review of hospital policies/procedures, medical records, hospital documents, and staff interviews, it was determined the hospital failed to:

1. require the Quality Assurance Performance Improvement (QAPI) activities identified and analyzed unanticipated outcome events and implemented effective corrective actions identified during a root cause analysis (RCA) conducted after the death of Pt #3 and failing to correct an immediate jeopardy deficient practice identified on 09/09/11 and 09/13/11; and

2. evaluated the hospital's services provided for 1 of 1 patients in an emergency situation (Pt #34).

Findings include:

1. Reference A0395 Condition of Participation: Nursing Services

2. Pt #34 presented to the hospital's north lobby requesting services on 01/26/11 at 1340, according to the occurrence report that was reviewed to verify the hospital's quality management processes. The report indicated that the office employee was escorting the patient through the hospital and across the courtyard when the patient "lost balance." The employee called the RN for assistance. Paramedics were ultimately summoned, and the patient was transported to an acute care hospital.

There was no medical record, transfer information, or other documentation. The report was processed as "closed...Severity Level: no harm." The DQM confirmed during an interview conducted on 09/07/11 at 1115, that there was no documentation verifying the steps taken to investigate the event, nor corrective action identified. The DQM further stated that occurrence reports are written for any patient however a medical record is documented only if the patient is admitted to the hospital.

The hospital's quality management program did not maintain documentation to verify that occurrence reports were investigated to evaluate services and recommend corrective action, to determine if policies were followed, documentation was complete, qualified personnel were in attendance, and emergency services were provided, to ensure occurrences of the same nature were not repeated.

Based on review of medical records, policies, procedures, direct observations, hospital documents, video surveillance, and staff interviews, it was determined the hospital failed to:

A0392: have adequate numbers of personnel available to meet the needs of 3 patients on the Hopi unit who were sleeping on mattresses, on the floor, in the hallway, during the night at 0330 hours on 09/16/11, with one behavioral health technician (BHT) responsible for monitoring the 3 patients (Pts #31, 32, and 33);

A0395: require a registered nurse supervised and evaluated the nursing services, as evidenced by:

a. the RN failed to require 7 of 7 patients on the Adobe Unit had every 15 minute intensive observation monitoring (Pt #'s 3, 21, 22, 23, 24, 25, and 26), with Pt #3 found unresponsive and stiff;

b. the RN failed to require 18 patients on the Adobe Unit on 09/10/11 at 0300 through 0339 hours, had adequate every 15 minute rounds and/or every 30 minute rounds as ordered by the physicians (Pts #27, 28, 29, and 30 required every 15 and 30 minute rounding);

A404: require nursing documented medications administered to Pt #3 who was found dead approximately 17 hours after admission to the hospital; and

A405: require the Methadone Usage Policy was implemented for patient safety for 3 of 4 patients (Pts #3, 18 and 19).

The cumulative effect of these systemic deficient practices resulted in the Hospital's failure to meet the requirements for the Condition of Participation for Nursing Services.

Based on review of policies/procedures, direct observations, and staff interviews, it was determined the hospital failed to have adequate numbers of personnel available to meet the needs of 3 patients on the Hopi unit who were sleeping on mattresses, on the floor, in the hallway, during the night at 0330 hours on 09/16/11, with one behavioral health technician (BHT) responsible for monitoring the 3 patients (Pts #31, 32, and 33).

Findings include:

The hospital policy titled Behavioral Health: Suicide and Self-Harm Precaution Protocol required: "...To provide a plan and interventions to control and prevent potentially harmful behavior of patients...To promote and maintain a safe and secure environment within the structure of the hospital setting...Any clinician/nurse who feels the patient presents as a suicide risk may initiate restriction of the patient to the unit and initiate observation level as indicated...Moderate...Eye Contact...Action: Patient is made physically visible to the assigned staff member at all times and is within hearing range while awake...."

During a tour of the Hopi Unit on 09/03/11 at 0330 hours, two patients were observed in the hallway and one in the group room on mattresses, on the floor. One BHT was observed sitting in the hallway within visual range of all patients. According to the BHT the patients were required to be within her visual range at all times, therefore, the mattresses and adolescents are brought out to floor in the hall and group room for ease of observation by the one BHT.

Senior Clinical Manager RN #22 confirmed on 09/16/11 at 0700 hours, that the hospital's practice is to bring the adolescents out to hallway so that one BHT can monitor more than one patient, otherwise, the hospital has to have more BHTs to monitor the patients in their rooms. She also confirmed Pt's #31 and 33 had physicians' orders for moderate suicide precautions requiring constant visual observation by personnel. Patient #32 had just returned from the hospital and the RN on duty implemented the precaution for the patient to be in constant visual contact with personnel for safety.

Based on review of medical records, policies, procedures, video surveillance, and staff interviews, it was determined the hospital failed to require a registered nurse supervised and evaluated the nursing services, as evidenced by:

1. the RN failed to require 7 of 7 patients on the Adobe Unit had every 15 minute intensive observation monitoring (Pt #'s 3, 21, 22, 23, 24, 25, and 26), with Pt #3 found unresponsive and stiff;

2. the RN failed to require 18 patients on the Adobe Unit on 09/10/11 at 0300 through 0339 hours, had adequate every 15 minute rounds and/or every 30 minute rounds as ordered by the physicians (Pts #27, 28, 29, and 30 required every 15 and 30 minute rounding).

Findings include:

The hospital policy titled Observation and Supervision of Patients, Routine required: "...Routine rounds are completed...every half hour on the Adobe unit 24 hours a day...If a patient is sleeping during rounds, and the room is dark or partially dark, the staff member is to illuminate the room sufficiently to view the patient in order to be able to observe the patient's respirations and determine that the patient is unharmed and resting. Any concern regarding quality of respirations, patient condition or status is to be reported to the nurse for further assessment...."

The hospital policy titled Behavioral Health: Suicide and Self-Harm Precaution Protocol required: "...Procedure/Interventions: Patient Monitoring: Monitor patient according to level of observation ordered and observe patient behaviors...Minimum Interventions...Behavioral Health Staff Interventions...Precautions: Suicide...." Patient Observation/Monitoring: Visual contact is to be maintained minimally every 15 minutes...Documentation: Observation documentation is recorded every 15 minutes...."

1. Patient #3 was admitted to the hospital on 09/17/10 at 1230 (noon time) hours for chemical detoxification from alcohol and heroin. The patient's admitting orders included: "...Restrict to unit on Q15 (every 15) minute behavioral observation until seen by attending physician/psychiatrist/psychiatric nurse practitioner...Precautions: Suicide...."

Review of documentation on the hospital Intensive Observation Form indicated the patient was observed every 15 minutes and the patient's location and behaviors were documented every 15 minutes for his entire admission.

On 09/18/10 nursing documented at 0545 hours, that the patient was not responsive to verbal stimuli and the behavioral health technician (BHT) notified the nurse. The patient was observed not to be breathing, without a blood pressure or pulse. Police documentation of the incident indicated they helped the staff move the patient onto the ground for cardiopulmonary resuscitation (CPR) and noted that the patient's legs were stiff.

The hospital conducted a Root Cause Analysis (RCA) of the event and after reviewing the video surveillance of the unit determined staff had not conducted the 15 minute rounding of the patient as ordered although staff documented conducting the 15 minute checks for Pt #3.

Employee #'s 7 and 4 confirmed the findings and information from the RCA on 09/07/11.

Patient # 21 was admitted to the hospital on 09/02/11 for a anxiety mood disorder, borderline personality disorder and recent suicidal ideation at 1800 hours. The patient's admitting orders included: "...Restrict to unit on Q15 minute behavioral observation until seen by attending physician/psychiatrist/psychiatric nurse practitioner...Precautions: Min (minimum) Suicide...."

Documentation on the night shift's (2330 hours - 0700 hours) intensive observation form for 09/03/11, indicated the patient was checked every 15 minutes.

Review of the video surveillance for 09/03/11 from midnight through 0200 hours, did not show staff checked the patient every 15 minutes as ordered. The staff checked the patient approximately every 30 minutes. Employee #21 confirmed the video findings.

Patient #22 was admitted after a suicide attempt on 09/02/11, with an anxiety disorder, alcohol and benzodiazepine abuse and dependence. The patient's admitting orders included: "...Restrict to unit on Q15 minute behavioral observation until seen by attending physician/psychiatrist/psychiatric nurse practitioner...Precautions: Min...Suicide...."

Documentation on the night shift intensive observation form for 09/03/11, indicated the patient was checked every 15 minutes.

Review of the video surveillance for 09/03/11 from midnight through 0200 hours, did not show staff checked the patient every 15 minutes as ordered. The staff checked the patient approximately every 30 minutes. Employee #21 confirmed the video findings.

Patient #23 was admitted on 09/02/11 at 1105 hours, with depression and recent suicidal ideation. The patient's admitting orders included: "...Restrict to unit on Q15 minute behavioral observation until seen by attending physician/psychiatrist/psychiatric nurse practitioner...Precautions: Min Suicide...."

Documentation on the night shift intensive observation form for 09/03/11, indicated the patient was checked every 15 minutes.

Review of the video surveillance for 09/03/11 from midnight through 0200 hours, did not show staff checked the patient every 15 minutes as ordered. The staff checked the patient approximately every 30 minutes. Employee #21 confirmed the video findings.

Patient #24 was admitted on 09/02/11 at 0845 hours with acute alcohol withdrawal syndrome. The patient's admitting orders included: "...Restrict to unit on Q15 minute behavioral observation until seen by attending physician/psychiatrist/psychiatric nurse practitioner...."

Documentation on the night shift intensive observation form for 09/03/11, indicated the patient was checked every 15 minutes.

Review of the video surveillance for 09/03/11 from midnight through 0200 hours, did not show staff checked the patient every 15 minutes as ordered. The staff checked the patient approximately every 30 minutes. Employee #21 confirmed the video findings.

Patient #25 was admitted on 09/02/11 with schizoaffective disorder. The patient's admitting orders included: "...Restrict to unit on Q15 minute behavioral observation until seen by attending physician/psychiatrist/psychiatric nurse practitioner...Precautions: Min Suicide...."

Documentation on the night shift intensive observation form for 09/03/11, indicated the patient was checked every 15 minutes.

Review of the video surveillance for 09/03/11 from midnight through 0200 hours, did not show staff checked the patient every 15 minutes as ordered. The staff checked the patient approximately every 30 minutes. Employee #21 confirmed the video findings.

Patient #26 was admitted on 09/02/11 with a major depressive disorder, that was recurrent with psychosis and an anxiety disorder. The patient's admitting orders included: "...Restrict to unit on Q15 minute behavioral observation until seen by attending physician/psychiatrist/psychiatric nurse practitioner...Precautions: Min Suicide...."

Documentation on the night shift intensive observation form for 09/03/11, indicated the patient was checked every 15 minutes.

Review of the video surveillance for 09/03/11 from midnight through 0200 hours, did not show staff checked the patient every 15 minutes as ordered. The staff checked the patient approximately every 30 minutes. Employee #21 confirmed the video findings.

The DQM and CNO confirmed on 09/09/11, that patient #'s 21, 22, 23, 24, 25, and 26, had current physician orders for intensive observation checks every 15 minutes during the night shift on 09/03/11.

This deficient practice was identified as a health and safety risk to patients on the Adobe Unit, resulting in an Immediate Jeopardy (IJ) situation

2. A tour of the Adobe Unit was conducted on 09/13/11 at 1330 hours, to evaluate the action plan instituted by the hospital for the IJ deficient practice. The Senior Clinical Manager (SCM) for the Adobe Unit was asked to review the action plan. According to the SCM all monitoring was completed and coaching was provided for staff who needed coaching. Employee #21, and the Associate Administrator reviewed the 2 video surveillance tapes for 09/10/11, from 0300 through 0500 hours and 09/11/11, from 0200 through 0400 hours. He confirmed the rounds were performed as ordered and no deficiencies were identified.

The Surveyors asked to view the video for 09/10/11 from 0300 through 0500 hours.

Review of the video revealed the following:

03:08:21 Rounds begin with 2 staff members exiting the nurses station heading towards rooms 611 and 612 (not in view of the camera);

03:08:56 Staff at room 613 (Pt #27), opened door and exited (closing the door) 3 seconds later at 03:08:59 hours;

03:09:04 Staff at room 614 (Pt #28), opened door and exited 2 seconds later at 03:09:06;

03:09:21 Staff at room 618 (Pt #29), opened door and exited 2 seconds later at 03:09:23;

03:09:31 Staff at room 619 (Pt #30), opened door and exited 2 seconds later at 03:09:33; and

03:09:33 rounds ended 73 seconds later.

Employee #21 and the SCM for Adobe confirmed the times for the rounds as labeled on the video.

A second patient rounding video was reviewed on 09/10/11 which revealed the following:

03:39:07 Staff at room 613 (Pt #27) and exited 2 seconds later at 03:39:09;

03:39:14 Staff at room 614 (Pt #28) and exited 3 seconds later at 03:39:17;

03:39:25 Staff at room 618 (Pt #29) and exited 3 seconds later at 03:39:28;

03:39:37 Staff at room 619 (Pt #30) and exited 4 seconds later at 03:39:41, staff noted patient was awake talking; and

Rounds were completed in 33 seconds. The SCM and Employee #21 confirmed the video timing for the rounds.

The video roundings reviewed showed staff did not enter the rooms and stood in the doorways with the doors ajar.

The CEO, SCM for the Adobe unit, and the CNO confirmed the that they had not reviewed the video. They could not confirm with certainty that the staff verified each patient was breathing. The documentation on the rounding sheet did not indicate the patients were snoring (a choice for documentation) to provide auditory confirmation of the patients' respirations.

Based on review of the video findings the CEO and Administrative Team were notified at 1900 hours on 09/13/11, the IJ was not abated at this time and concluded that patients on the Adobe Unit were at risk for health and safety.

Based on review of medical records, hospital documents, policies/procedures, and staff interviews, it was determined the hospital failed to require nursing to document medications administered to Pt #3 who was found dead approximately 17 hours after admission to the hospital.

Findings include:

The hospital policy titled Safe Medication Administration required: "...Procedural documentation: Document...The drug dose, time, route and administrator's initials immediately after administration...Medications not given and reason...."

According to the Pyxis dispensing sheet for Pt #3, the following medications were pulled from the Pyxis dispensing unit:

09/17/11: 17:57, Imodium 4 milligrams (mg);
09/17/11: 17:59; Bentyl 20 mg;
09/17/11: 19:59; Methadone 15 mg

The Director of Pharmacy confirmed during an interview on 09/08/11, that the Pyxis log showed Pt #3 had the above medications pulled from the Pyxis and the log did not indicate staff returned those medications to the Pyxis.

Review of Pt #3's medication administration record (MAR) did not have documentation that the patient received these medications or that the medications were not given.

The SCM for the Adobe unit confirmed on 09/02/11, that Imodium 4 mg, Bentyl 20 mg and Methadone 15 mg were pulled from the Pyxis on 09/17/11, and were not documented on the MAR as administered. Additionally, the SCM confirmed the hospital did not identify this deficient practice during the RCA for Pt #3.

Based on review of medical records, policies, procedures, and staff interviews, it was determined the hospital failed to require the Methadone Usage Policy was implemented for patient safety for 3 of 4 patients (Pts #3, 18 and 19).

Findings include:

The hospital policy titled Methadone Usage Policy required: "...Maintenance...Maintenance doses may be continued for patients admitted for diagnosis other than opiate withdrawal only after dose has been verified. The doses will be documented in the medical record along with the name of the clinic and the date and time of the last dose...."

Review of Pt #3's medical record revealed the patient was sent from the sending facility and arrived at the hospital on 09/17/10 around 1230 (noon time). The admitting diagnoses on the order sheet from the the sending facility on 09/17/10, were: "...amphetamine/ opioid- alcohol- cannibus depend (dependency); ASPD (antisocial personality disorder)...." The order sheet indicated the patient was admitted to the adult chemical dependency program for detoxification.

According to documentation from the ending facility on their medication reconciliation form the patient was taking the following medications: Methadone 15 milligrams (mg) orally every morning; Remeron 45 mg orally at bedtime; and Klonopin 2 mg orally twice a day. These doses were obtained from the patient.

The hospital confirmed the staff did not verify the Methadone doses for Pt #3 during their root cause analysis (RCA).

Review of Pt #18's medical record indicated the patient was admitted on 06/23/11 for chemical detox from alcohol and suicidal ideation.

On 06/23/11 the physician requested Methadone 115 mg orally every morning be continued for the patient on.

Patient #18 received Methadone while in the hospital.

Patient # 19 was admitted on 06/23/11 with suicidal ideation and dysthymic disorder.

On 06/23/11 the physician requested Methadone 17 mg orally every morning be continued for the patient.

The DQM, CNO, and SCM for the Adobe Unit all confirmed on 09/09/11 at 0900 hours, that for Pt's #18 and 19, nursing did not document the date and time of the last dose of Methadone prior to administering the Methadone, as required by policy.