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Based on policy review, medical record reviews, and staff interviews, the hospital's staff failed to ensure a physician's written or telephone/verbal order for restraint was obtained and documented in the medical record for 1 of 3 restraint records reviewed (Patient #7).

Findings included:

Review on 01/11/2017 of current policy "Seclusion/Restraint (S/R)", Policy No.: PC-1-009, last reviewed: 05/16/2014, revealed "...PHYSICAL RESTRAINT/HOLD: ...PROCEDURE: ...4. The Physician/RN (Registered Nurse) assesses the need for restrictive intervention and a written or telephonic order is obtained from the physician for the S/R on the Seclusion/Restraint Order form as follows: *Adults 18 and older up to 4 hours ...*The physicians' orders specify the reason for restraint and seclusion usage, the type of restraint and their duration. ...*In an emergency, the Nursing Supervisor/Unit Nurse may initiate a S/R as a protective measure provided that a physician order is obtained as soon as possible, but no longer than 1 hour after initiation of S/R ...".

Closed medical record review on 01/11/2017 for Patient #7 revealed a 19 year old male admitted to the hospital on 12/28/2016 and discharged on 01/07/2017 with a diagnosis of Intermittent Explosive Disorder and Autism Spectrum Disorder, Non-psychiatric. Review of an "RN Seclusion & Restraint Note" dated 01/03/2017 by an RN, revealed the patient was placed into "Physical Restraint" on 01/03/2017 at 1400 and released at 1401 (1 minute). Clinical justification for initiation of restraint was, "Patient (male) became agitated with a peer (female) after the peer cursed at him for asking her to 'hurry up and eat'. Patient then tried to physically assault female patient." Further record review failed to reveal any available documentation of a physician's written or telephone/verbal order for restraint being obtained by the RN for the physical restraint on 01/03/2016 at 1400.

Interviews on 01/11/2017 at 1411 with DON #1 (Director of Nursing) revealed a physician's order was required for restraint. The order must be documented in the medical record. After reviewing Patient #7's medical record, no documentation of a physician's written or telephone/verbal order for restraint could be found for the physical restraint on 01/03/2017 at 1400. Interview confirmed the medical record review findings.

Interview on 01/11/2017 at 1415 with NM #2 (Nurse Manager) revealed a verbal order was obtained by staff from the physician, but it was not written down and placed into the patient's medical record. The verbal order should have been written in the medical record. Interview confirmed the medical record review findings.

Based on the hospital's "Performance Improvement Plan" review, Performance Improvement (PI) activities data review, and staff interview, the hospital's leadership staff failed to implement preventive actions and mechanisms to reduce the hospital's identified performance improvement indicator for patient aggressions.

Findings included:

Review on 01/12/2017 of the hospital's "Performance Improvement Plan" (Approved Date 01/28/2016), revealed "I. Introduction: The Program for Performance Improvement (PI) of (Hospital Name) involves a planned systemic, organization-wide approach to process, design and performance measurement, analysis and improvement. II. Purpose: 3. Collecting data to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement and sustain improvement. VII. Improve: The goal of improving the performance of the organization is realized by taking improvement actions that address root causes, involve the right people and result in desired and sustained change. The methodology utilized is the FOCUS - PDCA to support the ongoing evaluation of improvement strategies and initiatives. Attachment 1...FOCUS - PDCA....FIND an opportunity to improve....ORGANIZE an initiative/team that knows the process....CLARIFY the process....UNDERSTAND the problem with the process....SELECT an appropriate approach to fix the problem".

Review on 01/12/2017 of the hospital's performance improvement activities data review for primary initiatives from the period of November of 2015 through November of 2016, revealed data collection numbers documented on form titled "Under Best Practices Identified to Remedy Issue" for "Patient Aggression with No Injury and Patient Aggression with Injury" monthly. Review of the montly numbers were as follows:

~11/2015 Patient Aggressions with no injury totaled 81, Patient aggressions with injury totaled 5;
~12/2015 Patient Aggressions with no injury totaled 78, Patient aggressions with injury totaled 5;
~01/2016 Patient Aggressions with no injury totaled 66, Patient aggressions with injury totaled 7;
~02/2016 Patient Aggressions with no injury totaled 43, Patient aggressions with injury totaled 5;
~03/2016 Patient Aggressions with no injury totaled 39, Patient aggressions with injury totaled 6;
~04/2016 Patient Aggressions with no injury totaled 65, Patient aggressions with injury totaled 5;
~05/2016 Patient Aggressions with no injury totaled 77, Patient aggressions with injury totaled 8;
~06/2016 Patient Aggressions with no injury totaled 79, Patient aggressions with injury totaled 7;
~07/2016 Patient Aggressions with no injury totaled 40, Patient aggressions with injury totaled 6;
~08/2016 Patient Aggressions with no injury totaled 92, Patient aggressions with injury totaled 9;
~09/2016 Patient Aggressions with no injury totaled 37, Patient aggressions with injury totaled 6;
~10/2016 Patient Aggressions with no injury totaled 80, Patient aggressions with injury totaled 11; and
~11/2016 Patient Aggressions with no injury totaled 84, Patient aggressions with injury totaled 10.

Review of the form titled "Under Best Practices Identified to Remedy Issue" for "Patient Aggression with No Injury and Patient Aggression with Injury", revealed that no methods to implement best practice or actions were found in the hospital's performance improvement documentation. The review of the hospital's performance improvement activities revealed the hospital failed to track adverse patient events for patient aggression with and without injury, analyze their causes, and implement preventive actions and mechanisms that included feedback and learning throughout the hospital.

Interview on 01/12/2017 at 1126 with the hospital's PI Director #1 revealed that the hospital's QAPI (Quality Assessment Performance Improvement) team had conversations during the monthly "Patient Safety Council" meetings for patient aggressions but the communication was not done with all disciplines at the hospital. The interview further revealed that the patient aggression numbers were high for some months and that nothing more for actions of patient aggression could be produced in the hospital's QAPI. Interview confirmed the QAPI data review findings.

Based on policy and procedure reviews, medical record review and staff interviews, the facility's nursing staff failed to supervise the nursing care of a patient by failing to respond to changes in a patient's condition to prevent a delay in medical treatment for 1 of 1 patients with a skin infection (#5).

Findings include:

Review on 01/12/2016 of policy and procedure, "Medical Response to Changes in Patient's Condition - Assessment/Reassessment" last reviewed on 05/16/2014 revealed, "The initial nursing admission assessment is based on physiological and psychological assessment data related to the following:...5) Skin assessment to include head checks...7) Medical history...D. On a 24-hour continuum, a patient's assessment may result in a change in status and depending on the severity of the assessment finding, on of the following systems are employed: 1) A non-emergent or non-urgent response that addresses a patient's well-being related to early signs of occurring medical changes that are not considered emergent or urgent at the moment of assessment findings....The RN (Registered Nurse)/LPN (Licensed Practical Nurse) may call the physician, may consult with the Nursing Supervisor, Nurse Manager or the Director of Nursing."

Review on 01/12/2016 of policy and procedure, "Nursing Assessment" last reviewed 05/13/2014 revealed, "....E. For all patients with an acute medical condition, the RN documents an assessment of the patient's condition at least once every 24 hours until resolved."

Closed medical record review on 01/10/2016 for Patient #5 revealed, a "Progress Note:" dated 11/29/2016 by Physician A. Review revealed, "1. Discharge Summary ...History of Present Illness ...A. Admission Date: 11/05/2016 ...Patient is a 14 year old female admitted voluntarily due to suicidal ideations, self-injurious behaviors, increased depression, increased anxiety elopement from home and poor impulse control....Patient has 2 previous inpatient treatments at (Hospital A name). Patient has previous diagnosis of Posttraumatic Stress Disorder, Depression and Attention Deficit Disorder..."

Review of a "NURSING ADMISSION NOTE (Page 2 of 11)" by a RN dated 11/05/2016 at 2140 revealed, "... Nursing Admission Assessment ...Skin ...Scratches/most on left Forearm..."

Review of the "Nursing Assessment/Reassessment" documentation for the following dates: 11/06/2016 through 11/11/2016 revealed: "...Skin Integrity ...No Concerns..." Further review revealed, on 11/12/2016 at 0151 Patient #5 complained of external "pain in (R) Right ear..." and no skin integrity concerns. Documentation by RN #5 dated 11/13/2016 at 0905 revealed, "Skin Integrity ...Abrasions (R) ear lobe..."

Review of the "Nursing Assessment/Reassessment" documentation for the following dates 11/14/2016 through 11/29/2016 revealed, documentation by a RN dated 11/14/2016 at 0348 "...notable 'scabbed over' area...covering right ear lobe, small circular scabbed over area on right cheek and over left orbit of eye - small amount of exudate....due for medical consult today..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/14/2016 at 0947 revealed, "...Open wounds....MD AWARE OF WOUND TO RIGHT EAR LOBE AND RIGHT CHEEK. NEW ORDERS RECEIVED..."

Review of "PHYSICIAN'S ORDER FORM" dated 11/14/2016 at 1251 revealed, "...Consult re: (reason) sores on face possible infection..."

Continued Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/14/2016 at 2205 revealed, "...Open wounds....Rash to R (right) ear lobe Cheek & (and) Shoulder - worsening daily..."

Review of "Nursing Assessment/Reassessment" documentaion by a RN dated 11/15/2016 at (date is illegible) revealed, "...Patient had faint Rash 11/10; larger & (and) scabbed 11/12; & was observed to have dry round scabbed areas covering R lobe; on scalp behind ear, & mid R neck & on shoulder..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/16/2016 at 1335 revealed, "...Pt. (patient) was seen by PA (Physician Assistant) order for MRSA (Methicillin Resistant Staphylococcus Aureus) swab to be done & Triple antibiotic TID (Three Times Daily) to affected areas..."

Review of a "CONSULTATION" note by a PA dated 11/16/2016 (not timed) [2 days after initial medical Consult Order] revealed, "...Recommendation: ...Rash - likely bacterial infection....Will prescribe Triple antibiotic ointment to are 3x daily....Will swab area For MRSA/ Staph..."

Review of a "PHYSICIAN'S ORDER FORM" dated 11/16/2016 at 0900 revealed, "Apply triple antibiotic ointment topically to affected area 3x (times) daily....swab for Staph/MRSA..."

Continued review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/16/2016 at 2146 revealed, "...R ear, side of neck MRSA swab to be collected...11-16-16 7p-7a ...Pt R ear & side of neck reddened (symbol -with) edema (symbol - no) drainage noted..."

Review of "Nursing Assessment/Reassessment" documentation by a RN on 11/17/2016 (not dated) revealed, "...pt. states that the rash/scabbed area has spread to other areas..." Review of "Nursing Assessment/Reassessment" by a RN dated 11/18/2016 at 0634 revealed, "...reminded patient once again this shift about good hand hygiene r/t (related to) scabbed areas on face and patient reporting scabbed areas having spread..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/18/2016 at 1643 revealed, "...Pt continues tx (treatment) for R Ear rash, no side effects noted or reported, slight improvement on skin condition noted..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/19/2016 at 1317 revealed, "...Open wounds, dry & Red on Right cheek bone, under Right eye, on Right ear & Right shoulder...Bacitracin applied per MD order..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/20/2016 at 0549 revealed, Pt. still has an infection to R ear, shoulder and cheeking, labs pending..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/20/2016 at 1445 revealed, "...Pt continues tx for rash in R ...ear, cheek & shoulder, improvement noted..."

Review of laboratory documentation revealed, a specimen for MRSA was collected on 11/18/2016 (2 days after ordered by PA) and the results "...MRSA Screening Culture... Negative..." were reported on 11/20/2016 (4 days after ordered by PA).

Continued review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/21/2016 (not timed) revealed, "...Open wound, dry scaly Red on R shoulder, R cheek bone, under R...eye and R ear. Bacitracin applied and new dressing..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/21/2016 at 2349 revealed, "...Pt has leigons (sic) to R ear & R cheek that are dried/ scabbed over. R eye is reddened & area on R shoulder draining scant amount of clear/blood tinged fluid. States she has similar ...lesions on abdomen/pelvic area..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/22/2016 at 1837 revealed, "...c/o (complain of ) eyes being 'glued shut, this AM' (symbol - with) redness..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/23/2016 at 0421 revealed, "...Pt continue tx for Rash in R Ear, cheek & should (sic - shoulder) improvement noted..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/24/16 at 0313 revealed, "...Pt continues tx for skin irritation as ordered improvement noted to ear cheek & shoulder, but pt eyes appear red & (symbol with) discharge..."

Review of the "PHYSICIAN'S ORDER FORM" dated 11/24/2016 at 0047 revealed, a consult telephone order placed by a MD for a "...Medical Consult....Bilateral Eye irritation (with) drainage..." (8 days after initial medical consult by PA).

Review of a "CONSULTATION" note dated 11/24/2016 (not timed) by a PA (8 days after initial medical consult) revealed, "...Pt seen for rash/ infection on ear lobe, Face and Shoulder Given triple antibiotic ointment, showed slight improvement. Now, seems to be getting worse - appears crusty, irritated, + (positive) itchy Eyes: Pt has bilateral eye irritation, + drainage- dischare (sic - discharge) conjunctiva appears red, ...Recommendation: Dx: Fungal infection...will d/c triple antibiotic ointment. Apply Lotrimin cream to affected area BID x 7 days..."

Continued review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/25/2016 at 0251 revealed, "...Continue Tx for ring worm and conjunctivitis, redness to eyes noted..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/26/2016 at 0319 revealed, "...Continue tx for ringworm and pink eyes (no) drainage noted from eye..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/26/2016 at 1924 revealed, "...Pt c/o of drainage from R ear upon assessment drainage is slightly yellow in color..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/27/2016 (not timed) revealed, "...Pt c/o small bump on back of neck only irritated no c/o pain but pt concerned..." Review revealed, there was not any documentation for a consult for the patient's concern of the new development of a small bump on back of the neck.

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/20/2016 at 1646 revealed, "...Pt reports improvement in wounds (with) current tx, compliant (with) tx..."

Review of "Nursing Assessment/Reassessment" documentation by a RN dated 11/29/2016 at 0517 revealed, "...Refused Lotrimin cream tonight. Pt states, 'I can't shower and it's not getting better. No point to use.' Rashes on face and shoulder noted. Redness eye noted but improve..." Review revealed, Patient #5 was discharged on 11/29/2016 at 1310. Review failed to reveal any available documentation of consult for the patient's concern of the new development of a small bump on back of the neck on 11/27/2016.

Interview on 11/12/2016 at 0958 with Physician A revealed, follow up to a consult should happen 24 to 48 hours afterwards by the consulting provider. Interview revealed, there were two consultations for Patient #5 and no documentation of follow-up by the provider.

Interview on 11/12/2016 at 1212 with RN #5 revealed, she remembered Patient #5 Interview revealed, there were only two consultations and she initiated both of them. Interview revealed, "I notified them that something should be done."

Interview on 11/12/2016 at 1119 with DON #1 revealed, the staff can initiate a consultation as well as consult follow-up. Interview revealed, "we expect staff to notify physician of change in conditions."

Based on policy reviews, observations, staff interviews, and personnel file reviews, the hospital's infection control officer failed to ensure hospital staff implemented established infection prevention measures for the prevention and control of infections and communicable diseases within the hospital; by failing to ensure staff performed hand hygiene after glove removal; and biohazardous waste (vomit) spill areas were cleaned and disinfected in a timely manner for 1 of 1 staff (Mental Health Worker [MHW] #6) observed cleaning up 1 of 1 biohazardous waste spill area (Spill #1).

Findings included:

Review on 01/11/2017 of current policy "Handwashing", Policy No.: IC-2-006, last revised: 12/29/2016 revealed, "...B. In the absence of a true emergency, hand washing is always indicated in the following situations: ...2. Before and after contact with blood, body fluids, mucus membrane or non-intact skin. 3. Before putting on or after removing protective gear. ...5. After handling contaminated equipment or articles. ..."

Review on 01/11/2017 of current policy "Handling and Disposal of Biohazard Waste", Policy No.: IC-2-05, last revised: 12/29/2016, revealed "...PROCEDURE: 1. Alert others in the area and isolate the contaminated area. (Prevent others from walking through or near the spill.) ...4. For larger spills (greater than 8 ounces) *Quickly contain spill by creating a circular berm around the perimeter of the spill with Super-sorb. ...*Sweep up granules (Super-sorb) with broom and dust pan and dispose of contents in red biohazard bag. *Clean spill area again with Comet with Bleach ad add materials to red biohazard bag. STAFF MEMBERS RESPONSIBLE FOR CLEANING: 1. Housekeeping *During hours that Housekeeping is scheduled to be in the hospital, it is Housekeeping Department's responsibility to clean area soled with biohazard waste. 2. House Supervisors * If the incident creating biohazard waste occurs at time when no Housekeeping staff is scheduled to work, it is the responsibility of the House Supervisor to clean the soiled area. 3. Unit Nurses * If the incident creating biohazard waste occurs at a time when no Housekeeping staff is scheduled to work, and the House Supervisor is not available, the nurse from the unit to which the patient is assigned will clean the soiled area."

Observation on 01/10/2017 during tour of 1 West (acute adolescent unit) at 1338 revealed MHW #6 entered the nurse's station, obtained disposable gloves, a red biohazard bag, and a container of Supra-Sorb (a liquid spill absorbent powder). The MHW exited the nurse's station and proceeded to clean up a large vomit (biohazardous waste) spill (Spill #1) from off the main hallway floor in-front of room 345. The MHW covered the vomit with Supra-Sorb powder and allowed it to absorb/dry. He then donned clean gloves and used a broom and dust pan to sweep up the Supra-Sorb granules and placed it into the red biohazard bag. As he completed sweeping, the patient (one who vomited) in room 345 requested something to drink. The MHW stated he would go get him some water from the cafeteria. The MHW did not clean the spill area again with a disinfectant solution and he did not isolate the area to prevent other patients and staff from walking through the spill area. The MHW exited 1 West and carried the biohazard bag to housekeeping staff for disposal. The MHW removed and discarded his contaminated gloves and walked into the cafeteria (clean area) and obtained a cup of ice water from the beverage machine (clean). The MHW exited the cafeteria and re-entered 1 West and gave the cup of ice water to the patient who was now in room 339. The MHW then went to the nurses' station and asked the RN to call for housekeeping. The RN paged for housekeeping (page #1). Staff and patients were observed traveling the hallway in-front of room 345. Observations revealed the MHW failed to wash his hands (contaminated) after removing his dirty gloves and before obtaining ice water from the cafeteria; and failed to clean the contaminated spill area again with a disinfectant solution; and failed to isolate the spill area to prevent other patients and staff from walking through it. As the Surveyor was exiting the unit the RN paged housekeeping again (page #2). At 1410 (32 minutes later) the Surveyor exited the unit and the biohazardous spill area had not been isolated from foot traffic nor disinfected. Observations revealed the biohazardous spill area had not been cleaned and disinfected in a timely manner and cross-contamination.

Interview on 01/10/2017 at 1415 with PI Director #1 present during the observations revealed she would have expected the MHW to remove his contaminated gloves and wash his hands before obtaining the ice water from the cafeteria. Interview confirmed the observation findings.

Interview on 01/12/2017 at 1140 with DON #1 revealed she was the hospital's infection control nurse and that staff receive education and training on infection control and hand hygiene. Staff are expected to use soap and water or an alcohol based hand rub to clean their hands after glove removal. The MHW did not follow hospital policy. Biohazardous waste spill areas are to be "immediately cleaned and disinfected." When housekeeping is not immediately available, the unit RN should disinfect the area or call for the Nursing Supervisor. Interview confirmed the observation findings.

Personnel file review on 01/12/2017 for MHW #6 revealed a date of hire of 12/07/2015. Review of a "Student and Group Transcript Report" generated on 07/01/2016 at 0803, revealed MHW #6 completed infection control training and hand hygiene training on 06/28/2016.

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