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The facility failed to ensure the Condition of Participation: CFR 482.13 Patient Rights was met by failing to ensure:

1. Based on interview and record review, the facility failed to establish a process for the referral of patients' complaints and grievances to the (QIO)Quality Improvement Organization (an organization charged with the review of quality of care concerns reported by medicare recipients). The failure precluded patients from being aware of their right to report a complaint or grievance to the QIO. (Cross Reference to A-0120).

2. Based on record review, and interview, the facility failed to: assess or reassess patient's pain, pre or post medication administration, in accordance with the facility's policy and procedure. These failures had the potential to provide inadequate pain control for Patients. (Cross Reference to A-0129)

3. Based on document review and interview the hospital failed to ask patients at the time of admission, whether the hospital should notify a family member or representative and the patients physician of their admission to the hospital. This failure has the potential of the patient's right for notification not occurring. (Cross Reference to A-0133).

4. Based on observation, interview and record review, the hospital failed to ensure a patient who was disrobing was accorded personal privacy. This failure resulted in the potential of the patient being visible to staff, patients and visitors. (Cross Reference to A-0143)

5. Based on observation, interview and record review, the hospital failed to ensure that patients were not confined without a physician order and secluded for appropriate management of behavior. This failure resulted in the potential for the patient to be secluded without the clinical justification for use and the behavior based criteria for use. (Cross Reference to A-0162)


6. Based on observation, interview and record review, the facility failed to implement less restrictive interventions for a patient prior to placing the patient in seclusion. This failure denied the patient the opportunity to have less restrictive interventions prior to being placed in seclusion. (Cross Reference to A-0165).


7. Based record review and interview, the hospital failed to modify the patients plan of care after the use of restraint and or seclusion. This failure has the potential of the treatment plan not reflecting the restraint and or seclusion intervention, assessment and evaluation. (Cross Reference to A-0166)

8. Based on interview and record review, the facility failed to ensure an physician's order for restraints was obtain timely, per policy and procedure. This failure had the potential for staff applying restraints to be practicing out of their scope of practice. (Cross reference to A-0168).

9. Based on observation, interview and record review,the facility failed to discontinue seclusion at the earliest possible time. This failure has the potential of continuing seclusion after the patient's behavior is no longer a threat to self, staff members or others.(Cross Reference to A-0174)

10. Based on interview and record review, the facility failed to ensure patients placed in seclusion and/or restraint, were seen face-to-face by a physician or a trained Registered Nurse (RN) within one hour after the initiation of seclusion or restraint. This failed practice has the potential of patients not being evaluated by a trained RN in order to determine if a serious medical or psychological condition existed, and/or to determine if the continued use of seclusion and/or restraints was necessary. (Cross Reference to A-0178)

11. Based on interview and record review, the facility failed to monitor patient's vital signs one hour after application of restraints (physical device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) per facility's policy and procedure. This failure place patients at risk of developing negative physiological outcome after the application of the restraints without being detected by staff. (Cross Reference to A-0179).

12. Based on interview and record review, the facility failed to ensure staff documented less restrictive measures were attempted before placing a patient in seclusion. This failure denied the patient the opportunity to have less restrictive interventions prior to being placed into seclusion.(Cross Reference to A-0186).

13. Based on observation, interview, and record review, the facility failed to ensure that the contract security staff who were responsible for monitoring and redirecting psychiatric patients were trained in the monitoring of a patient who was on a psychiatric watch (monitoring of psychiatric behavior). This failure has the potential to put patients and others at risk. (Cross Reference to A-0196).

The cumulative effect of these deficient practices resulted in the condition of participation for patient rights not being met.

Based on observation, interview, and record review, the facility failed to establish a process for the referral of patients' complaints and grievances to the (QIO)Quality Improvement Organization (an organization charged with the review of quality of care concerns reported by medicare recipients).

The failure precluded patients from being aware of their right to report a complaint or grievance to the QIO.

Findings:
The facility policy and procedure titled "Patient Complaint Advocacy" dated 8/1/2015, does not reference the QIO and provide contact information for patients.

During an observation on 5/1/2018, at 3:10 p.m., in the IPU (Inpatient Psychiatric Unit), no information about the QIO was noted to be available on the unit.

The facility's Patient Information Booklet provided to patients upon admission does not reference the QIO and provide contact information for patients.

During and interview on 5/3/2018 at 3:55 p.m., the administrator (ADM 2) confirmed there is no process in place to provide QIO contact information to patients.

Based on record review, and interview, the facility failed to: assess or reassess patient's pain, pre or post medication administration, for three of five sampled patients ( Patients 102,105 and 107) in accordance with the facility's policy and procedure.

These failures had the potential to provide inadequate pain control for Patients 102,105 and 107.

Findings:

The facility policy and procedure titled, " Patient Rights," dated 9/1/2016, indicated "You have the right to have your pain or discomfort assessed and treated."

The facility policy and procedure titled. " Pain Management," dated 7/26/2017, indicated, "Procedure: Staff at ( name of hospital) respect and support the patient's right to appropriate assessment and management of pain as the Fifth Vital Sign. This includes the initial assessment of the character of pain, and periodic reassessment as clinically needed and relevant to the patient's ongoing care and treatment...Initial Assessment...2. a. The RN/CNA performing the initial assessment will ask the patient to rate the intensity of the pain on a 0-10 scale utilizing the most appropriate pain scale tool for that patient...This information will be documented. ...4. The patient's response to the pain management intervention(s) will be assessed and documented. "Reassessment"...."1. The patient will undergo re-screening for pain during routine vital signs assessment and after every pain management intervention ( usually 30-60 minutes afterwards, based upon the intervention utilized). ...4. All pain screenings, assessments, interventions, and the patient's responses to treatment will be documented by the nurse and/or physician."

During an interview with licensed nurse (LN 6), on 5/3/2018, at 9:15 a.m., and concurrent record review of Patient 105, revealed that Patient 105 received ibuprofen (non-steroidal anti-inflammatory drug) 600 milligrams (mg) PRN (as needed) on 5/2/18, at 9:17 p.m., with no pain assessment documented prior to administration. LN 6 confirmed there was no pain assessment documented prior to administrating the medication.

During an interview with an administrator (ADM 4), on 5/3/2018, at 10:30 a.m., and concurrent record review of Patient 107, revealed that Patient 107 received ibuprofen 600 mg for pain on 5/2/18, at 8:17 a.m., the post assessment an hour later stated effective. No numerical pain scale documented. On 5/3/18, at 8:16 a.m., Patient 107 received Ibuprofen for pain and there was no pain assessment documented prior to administration of the medication. ADM 4 confirmed that both of these assessments were not documented.

During and interview with ADM 4, on 5/3/2018, at 10:45 a.m., and concurrent record review of Patient 102, revealed that Patient 102 received acetaminophen ( medication to treat mild to moderate pain and fever) 650 mg for pain. No pain assessment was documented prior to administering the medication. ADM 4 acknowledged no pain assessment was documented.

Based on document review and interview the hospital failed to ask patients at the time of admission, whether the hospital should notify a family member or representative and the patients physician of their admission to the hospital.

This failure has the potential of the patient's right for notification not occurring.

Findings:

On 5/2/18, starting at 9 a.m., during a interview with an administrator (ADM 1), ADM 1 was asked if there was a policy and procedure for family and physician notification of patient's admissions. ADM 1 stated, "No, we don't have those policies or procedures." While reviewing regulation text and current procedures, ADM 1 acknowledged facility currently does not have a procedure in place.

Based on observation, interview and record review, the hospital failed to ensure personal privacy for Patient 101.

This failure resulted in the potential of the patient being physically visible to staff, patients and visitors.

Findings:

During observation of video cameras and concurrent interview on 5/2/18 at 3:15 p.m. an administrator (ADM 1), recorded video revealed Patient 101 disrobed in her room on 4/30/18 at 3:42 p.m. and 5:14 p.m.. The staff providing "enhanced observation were out in the hallway" and included a male security guard sitting with staff outside her room."

During observation of the video cameras, ADM 1 asked staff in the nursing station if they could identify staff in the video. Staff in another room with windows were able to view the video. The video of Patient 101 disrobing was readily visible to all staff, other patients and visitors through the windows.

During observation and concurrent interview on 5/1/18 at 4:20 p.m., Patient 101 was laying on her bed. A male staff, a male security guard and a female staff were seated directly outside her open door. Patient 101 reported she didn't know who to talk to. Patient 101 confirmed she didn't know who they were.

During interview on 5/3/18 at 9:45 a.m., Patient 101 stated: "They said to keep your clothes on," Patient 101 stated: "No, they didn't tell me it had cameras."

During record review of Patient 101's clinical record on 5/1/18 at 12:47 p.m., the physician admission note dated 4/30/18 revealed that the doctor discussed the level of supervision for this patient upon admission with the inpatient psychiatric unit registered nurse (LN 1). The doctor wrote "due to staffing shortage, will place on 1:2 in the admission hallway." (The admission hallway is a corridor with four rooms which have cameras for continuous observation at locations in other rooms.)

During record review, the physician progress note dated 5/1/18 stated the patient was "repeatedly disrobing" on the out-patient observation unit prior to admission to the hospital and "she required 1:1 level of supervision for most of the day."

During record review of the progress note by the nurse dated 4/30/18 at 6:18 p.m., it was revealed that "upon admission, was placed on 1:2 continuous monitoring because of continued disrobing and running out in the hallway."

During interview on 5/3/18 at 10:25 a.m., the doctor (MD 1) stated " because she was disrobing she went to seclusion which was discussed with LN 1. Typically we arrange staff. Ideally I would have liked her on a 1:1 but we didn't have the staff, went 1:2." MD 1 confirmed that cameras are in the seclusion/restraint room to which Patient 101 was admitted and that "patients shouldn't be able to see" other patients. MD 1 stated that he was "unaware of it's visibility".

Based on observation, interview and record review, the hospital failed to ensure a physician order was obtained prior to putting Patient 101 in seclusion (a type of restraint). The hospital failed to follow it's policy and procedure regarding seclusion.

This failure resulted in the potential for the patient to be secluded without the clinical justification for behavior based criteria.

Findings:

1) The facility policy and procedure titled "Restraint and Seclusion in the IPU," indicated, "seclusion is the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving and an order must be obtained."

During observation and concurrent interview on 5/1/18 at 4:10 p.m., Patient 101 was laying on her bed. A male staff, male security guard and female staff (LN 8) were seated directly outside her open door. Patient 101 said she wanted to come out of her room, but didn't know if she could leave the room. Patient 101 reported she didn't know who to talk to. Patient 101 acknowledged that she didn't think she could walk in the hall or leave her room. Patient 101 confirmed she didn't know who the three staff were sitting outside her door and felt she had to stay in the room.

During interview on 5/1/18 at 4:20 p.m., LN 8 stated "they would have to ask the nurse if she could come out" and effectively secluded Patient 101.

During interview on 5/1/18 at 4:22 p.m.., licensed nurse (LN 9) confirmed that Patient 101 could come out of her room with the statement "of course, let her take her clothes off" and that there was no order for seclusion.

2) The facility policy and procedure titled "Restraint and Seclusion in the IPU," indicated, "seclusion may only be used for the management of violent or self-destructive behavior."

During observation and concurrent interview with administrator (ADM 1) on 5/2/18 at 3:15 p.m., the recorded video tapes of Resident 101 behaviors were observed on 4/30/18 from 15:42 (3:42 p.m.) to 2400 (midnight). The tapes revealed:
3:42 p.m.- Patient 101 resting on bed, the patient disrobes and dresses again.
5:10 p.m.- Licensed nurse (LN 10) goes into patient room
5:20 p.m.- Patient 101 disrobes, stands at almost closed door and then dresses and lays back down
5:21 p.m.- Physician Order received for "Seclusion Danger to Self - running naked, putting self in harm's way"
9:21 p.m.- Physician Order received for "Seclusion for Danger to Self - Disrobing"

ADM 1 stated that "the nurse (LN 10) perceived her as danger to self because of the male patient in the next room. She was watching both (male and female patient) at once."

During interview on 5/2/18 at 8:45 am, LN 10 stated "the other patient (Patient 201) is violent and unpredictable - that's why security is here all the time."

During interview on 5/3/18 at 10:00, the doctor (MD 1) stated that the disrobing is a danger to self due to her history, "it makes her vulnerable to inappropriate actions toward her." MD 1 stated "disrobing in the room is not a reason, the patient in the next room is a problem, so if the patient exits the room, it's not safe."

Based on observation, interview and record review, the facility failed to implement less restrictive interventions for Patient 301, prior to placing in seclusion.

This failure denied Patient 301 the opportunity to have less restrictive interventions attempted before being placed in seclusion.

Findings:

During an observation of a stored video recording for Patient 301's seclusion event that occurred on 4/23/18, from 9:15 a.m., until 10:26 a.m., and a concurrent interview with an administrator (ADM 1), the video recording revealed that after a altercation between Patient 301 and a another unsampled patient occurred, Patient 301 was immediately escorted to the seclusion room. ADM 1 explained that the other patient involved in the altercation was directed to go to his room.

Patient 301's clinical record revealed Patient 301 was placed in the locked seclusion room on 4/23/18, at 9:15 a.m., until 10:26 a.m. The clinical record lacked documentation of attempts at implementing less restrictive interventions prior to placing Patient 301 in seclusion.

During an interview on 5/2/18, at 10:45 a.m., with licensed nurse (LN 2) who was assigned to Patient 101 on 4/23/18, LN 2 acknowledged Patient 301 on 4/23/18 at 9:15 a.m. was placed in seclusion. LN 2 acknowledged less restrictive measures were not used prior to placing Patient 301 in seclusion. LN 2 confirmed the other unsampled patient involved in the altercation was directed to his room while Patient 301 was escorted to the seclusion room.

Based record review and interview, the hospital failed to modify 9 patients' (Patients 101, 401, 402, 403,404,405,406, 407, and 408)) plan of care after the use of restraint and/or seclusion.

This failure has the potential of the treatment plan not reflecting the restraint and or seclusion intervention, assessment and evaluation.

Findings:

The facility policy and procedure titled "IPU Treatment Planning", revised 7/26/17, under the Multidisciplinary Treatment Plan Review, indicated in part... "4. The Multidisciplinary Treatment Plan review will include: a. Problems as identified by the Team in the initial Multidisciplinary Treatment Plan. b. Progress towards goals. c. If modification is required, document the changes for each discipline."

During an interview and concurrent record review on 5/2/18 at 12:20 p.m., the administrator (ADM 4) acknowledged the medical records for Patient 101, 401, 402, 403, 404, 405, 406, 407, and 408 did not have treatment plans updated after each incident of seclusion and/or restraints.


35399

During an interview with licensed nurse (LN 4), on 5/3/18, at 10:40 a.m., LN 4 stated,"The care plans or multidisciplinary treatment plans do not need to be updated or revised because the patient's issues are the same."

During an interview on 5/3/18, at 10:40 a.m., licensed nurses (LN 5) stated, "After the patient's restraints are removed with the next multidisciplinary treatment plan meeting the members should update the treatment plan describing the situation ... The same applies to patient's placed in seclusion."

Based on interview and record review, the facility failed to ensure a physician's order was obtained timely, when Patient 302 was placed in restraints.

This failure had the potential for staff applying patient restraints, to be practicing out of their scope of practice.

Findings:

The facility policy and procedure titled "Restraints and Seclusion in the IPU", revised 4/16/18, indicated, "a. Restraints order shall be obtained from a physician member of the medical staff or a house officer under the supervision of an attending physician prior to application of the restraint. b. In an emergency a registered nurse may initiate restraint or seclusion to protect the patient or others from injury. An order must be obtained as soon as the situation that required the application of restraint is stabilized."

A review of Patient 302's clinical record revealed Patient 302 was admitted to the inpatient psychiatry unit (IPU) on 4/18/18, and restraints were applied at 9:15 a.m. A physician's restraint order was entered and electronically signed on 4/18/18, at 11:10 a.m. Further review of the clinical record did not reveal a physician verbal or telephone orders prior to the 11:10 a.m., physician restraint order entry.

During a concurrent clinical record and interview with the administrator (ADM 6), on 5/1/18, at 10:20 a.m., an administrator (ADM 6) acknowledged the restraint order for Patient 302 was not entered and signed timely by the physician.

During an interview with the administrator (ADM 7), on 5/1/18, at 10:25 a.m., ADM 7 acknowledged and agreed the restraint order for Patient 302 was entered and signed two hours after the restraints were applied.

Based on observation, interview and record review, the hospital failed to discontinue seclusion at the earliest possible time for Patient 101 according to the hospital's policy and procedure.

This hospital failure has the potential to inappropriately confine patients who do not exhibit behavior that is a danger to themselves or others.

Findings:

The facility policy and procedure titled, "Restraint and Seclusion in the IPU (inpatient psychiatric unit)," revised 7/1/2015, indicated: " Section 4. Discontinuation Criteria...seclusion shall be discontinued when the behavior or condition which was the basis for the seclusion order is resolved, regardless of the duration of the enabling order."

During observation of recorded video tape, concurrent interview and record review on 5/2/18 at 3:15 p.m., the administrator (ADM 1) acknowledged Patient 101 was placed in seclusion with an order on 4/30/18 at 5:21 p.m. A renewal of the seclusion order was written on 4/30/18 at 9:21 p.m., stating Patient 101 was a "Danger to Self - Disrobing." ADM 1 acknowledged the video recording showed the patient had not disrobed for approximately three hours prior to the written order. The camera recording revealed patient was resting and/or sleeping with no dangerous or violent behavior from 8:57 p.m. until 00:00 (midnight). ADM 1 stated, "she (the nurse) took it off at midnight. The patient was in room, resting on bed prior." The seclusion order was discontinued on 5/1/18 at 00:00 (midnight) resulting in Patient 101 being in seclusion for "6.65 hours."

During record review on 5/2/16 at 3:39 p.m., the IPU progress note by licensed nurse (LN 12) revealed that Patient 101 "was sleeping soundly after eating snack and received Ativan (medication used for anxiety disorders) 2 milligrams (mg) PO (by mouth) at 9:53 p.m.. There was no behavioral issues after that. The door was opened at 00:00 (midnight) and the patient is back on nursing 1:2."

Based on interview and record review, the facility failed to ensure 3 patients (Patient 301, 303, and 401) had face-to-face assessment (documentation of patients in restraints/seclusion to indicate a) immediate situation, b)reaction to the intervention, c) medical and behavioral condition and d) need to continue or terminate the restraint or seclusion). by a physician or a trained Registered Nurse (RN) within one hour after the initiation of seclusion or restraint.

This failed practice resulted in patients not being evaluated by a trained RN in order to determine if a serious medical or psychological condition existed, and/or to determine if the continued use of seclusion and/or restraints was necessary.

Findings:

Facility policy and procedure titled, "Restraint and Seclusion in the IPU ," dated 7/1/15, indicated, " 5. Monitoring and assessment. a. One hour face to face assessment: The physician or an appropriately trained registered nurse or physician's assistant shall perform a face to face assessment of patients physical and psychological status within one hour of the initiation of the restraint or seclusion and document."

Facility policy and procedure titled, "Nursing Education Plan," dated 9/15/17, indicated: "The Clinical Manager of Education in conjunction with the Nursing Unit Clinical Manager is responsible for ensuring all nursing staff: 1) Receive mandated education... 4. Will be assigned duties with validated documented competency."

1.) During a review of Patient 301's clinical record and concurrent interview on 5/2/18 at 9:35 a.m., the administrator (ADM 2) acknowledged Patient 301 was placed in seclusion on 4/23/18, from 9:15 a.m. to 10:26 a.m. and there was no physician's 1 hour face-to-face evaluation documentation. ADM 2 reported licensed nurse (LN 2) did document within 1 hour of patient being place in seclusion. ADM 2 explained that the nurses who have been trained to do a 1 hour face-to-face evaluation are identified and placed on a "Qualified Nurse List." ADM 2 acknowledged LN 2's name was not located on the "Qualified Nurse List."

2.) A review of the clinical record and concurrent interview on 5/2/18, at 4:00 p.m., the administrator (ADM 4) acknowledge the clinical record revealed Patient 303 was placed in restraints on 2/22/18, at 6 a.m., and removed from restraints on 2/22/18, at 7:20 a.m. ADM 4 acknowledged and confirmed there was no physician 1-hour face-to-face evaluation documented. Clinical documentation indicated licensed nurse (LN 11) performed the 1-hour face-to-face evaluation on 2/22/18.

During a review of the"Qualified Nurse List," and concurrent interview on 5/3/18, at 9:45 a.m., ADM 2 confirmed LN 11's name was not on the list as a qualified nurse who is trained to performed a 1- hour face-to-face evaluation on patients who are in restraints or seclusion.

3.) Record review of Patient 401's restraint and seclusion documentation indicated Patient 401, was placed in restraints on 5/1/18, at 9 a.m. Further review indicated licensed nurse (LN 7) performed the one hour face to face assessment.

During a interview with the administrator (ADM 3) and concurrent employee file review on 5/2/18, at 3 p.m., LN 7 employee file lacked competencies for trained face to face assessments. ADM 3 stated, "We are missing the competencies...These staff should have completed their competencies and then they can do face to face evaluations."




38585

Based on interview and record review, the facility failed to monitor patient's vital signs one hour after application of restraints (physical device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for three patients (Patient 302, 304 and 306) as indicated by the facility's policy and procedure.

This failure place patients at risk of developing negative physiological outcome after the application of the restraints.

Findings:

The facility policy and procedure titled "Restraint and Seclusion in the IPU (inpatient psychiatric unit)," revised 4/16/18, under the Monitoring and Assessment, indicated,"c.(ii)"The assessment shall include the following... 4. Vital Signs; vital signs within one hour of initiation then every four hours. (Please note while in restraints, a patient may not refuse vital signs due to safety concerns)."

1. During a review of the clinical record and concurrent interview, administrators (ADM 3 and ADM 4) acknowledged the clinical record revealed Patient 302 was placed in five point keyed leather restraint (arms, legs and chest area secure to bed/gurney by leather straps) on 4/18/18, at 9:10 a.m., restraints were removed at 10:50 a.m., on 4/18/18 and no vital signs taken while Patient 302 had restraints applied.

2. During a review of the clinical record and concurrent interview on 5/2/18 at 12:54 p.m., ADM 3 and ADM 4 acknowledged the clinical record revealed Patient 304 was placed in five point keyed leather restraint on 3/21/18, at 1:45 p.m., restraints were removed at 5:10 p.m., on 3/21/18 and no vital signs were recorded during the time Patient 304 was in restraints.

3. During a review of the clinical record and concurrent interview on 5/2/18 at 4:30 p.m., ADM 4 acknowledged the clinical record revealed Patient 306 was placed in five point keyed leather restraints on 3/15/18, at 8:15 p.m., restraints were removed on 3/15/18, at 10:20 p.m., and no vital signs were taken during the time the patient was in restraints (3/15/18, from 8:15 p.m. until 10:20 p.m.).

Based on interview and record review, the facility failed to ensure staff documented less restrictive measures were attempted prior to placing Patient 301 in seclusion.

This failure denied Patient 301 the opportunity to have less restrictive interventions before being placed in seclusion.

Findings:

During a record review and concurrent interview on 5/2/18 at 10:45 a.m., licensed nurse (LN 2) acknowledged there were no alternative interventions documented for Patient 301 prior to being placed in seclusion on 4/23/18, at 9:15 a.m., until 10:26 a.m.

Based on observation, interview, and record review, the facility failed to ensure that the contracted security staff, responsible for monitoring and redirecting psychiatric patients, were trained in the monitoring of a patient who was on a psychiatric watch (monitoring of psychiatric behavior).

This failure has the potential to put patients and others at risk.

Findings:

Review of facility policy and procedure, titled, "Nursing Education Plan," dated 9/15/17, indicated in part... under procedure, "Will be assigned only duties with validated documented competency." ... Under title "Staff development Programs," indicated in part... "Competency assessment (including temporary staff), ... Joint Commission and Title 22 compliance issues..." ...

During a concurrent observation and interview with security guard (SG 1) and licensed nurse (LN 10), on 5/1/18, starting at 8:40 a.m., SG 1 was observed to be sitting outside of patient rooms in the Admission/Seclusion Hall - doors were open to a female room and a male room. SG 1 was sitting with two female staff directly in sight of both rooms. SG 1 stated,"My role as security is, I just wait until (Patient 201) does something. We try to re-direct but if that doesn't work and we escort him back to his room."

SG 1 stated, "I am always at the door for (Patient 201) when the door is open." The door was closed, and a paper towel was folded and inserted at the lock site to prop the door from being locked.

At 8:45 a.m., LN 10 who was observed watching two patients stated, "(Patient 201) is violent and unpredictable and that is why the SG 1 is there all the time."

Further observation on 5/1/18, at 4:24 p.m., revealed a female patient (Patient 101), was observed laying on her bed with her door open and 2 staff (1 male and 1 female) along with SG 1 sitting outside her room talking amongst themselves. Patient 101 was observed asking if she could come out of her room. Licensed nurse (LN 8) said she didn't know if she could. The male staff and SG 1 nodded their heads and confirmed they didn't know either. All three staff agreed they would have to ask the RN before letting the patient come out of the room.

During a concurrent observation and interview with an administrator (ADM 1), on 5/2/18, at 3:15 p.m., while reviewing stored video of Patient 101 being placed into seclusion room, ADM 1 stated, "The nurse (LN 10) perceived that the female patient (Patient 101), who was disrobing in her room, as a Danger to Self because of the male patient (Patient 201) was in the next room. LN 10 was watching both patients at once with the Security Guard, that is why staff called the doctor and put (Patient 101) in seclusion." Further video tape observation revealed, prior to the order for seclusion, Patient 101 had been taking her clothes on and off and going to the door window in her room, the door was closed. The male Security Guard was observed sitting outside her door.

During a interview on 5/3/18, starting at 11:30 a.m., with ADM 1, a review of SG 1's employee file did not contain evidence that SG 1 had met a competency criteria for the monitoring of a patient on a psychiatric unit. ADM 1 acknowledged that the security staff assigned to the psychiatric inpatient unit were frequently responsible for observing and redirecting patients in the care setting. The ADM 1 acknowledged the security contract did not reflect facility competency requirements.

Based on record reviews and interview, the facility failed to address Diabetes Mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) in the nursing care plan for one patient (Patient 212).

This facility failure had the potential to result in the patient experiencing hyperglycemia or hypoglycemia (high or low blood sugar), leading to coma or death.

Findings:

The facility policy and procedure titled "MST.48 Nursing Care Plan", last approved 10/1/16, indicated, "The individualized patient care plan will be based on nursing diagnosis standards and tailored by the RN for each individual patient as necessary. The nursing care plan will address the patient's problems both actual and potential with appropriate goals/expected outcomes and nursing interventions to reach the stated goals."

During an interview on 5/2/18 at 11:55 a.m. with Patient 212, Patient 212 indicated she was going home today. Patient 212 stated, "I would like one of those machines (glucometer - a medical device for determining the approximate concentration of glucose in the blood) and a book so I know what I can eat". She also indicated that she had not been involved in the planning of her care while hospitalized.

During an interview on 5/2/18, at 3:20 p.m., LN1 acknowledged there was no nursing care plan addressing interventions for Diabetes Mellitus for Patient 212.

During a review of the clinical record for Patient 212, in a document titled "ED Note-Physician" dated 4/30/18, it was noted that admission glucose (sugar) level was 575 (a normal blood sugar level is between 72 mg/dL and 108 mg/dL for a healthy person). MD notes indicated that the Patient 212 was given a prescription of Metformin and the importance of close follow-up for management of her diabetes was discussed.

In a document titled "Multi-Disciplinary Treatment Plan"dated 5/1/18, in the "Nursing" section, there was no mention of Diabetes Mellitus in the section titled, "Nursing Problems".

Based on observation, interview, and record review, the facility failed to ensure medications, equipment, and supplies stored in the crash cart (emergency cart) were checked according to facility instructions.

This failure had the potential for medications, eqiuipment, and supplies needed to resuscitate a patient in an emergent situtation being unavailble and/or not functioning properly.

Findings:

The facility's instructions on the Crash Cart Checklist states "The Crash Cart is to be checked each calendar day. Your signature and lock number below indicate that the cart is properly locked, the supplies have been checked....."

The facility's checklist for 4/12/2018 and 5/2/2018 did not contain evidence the cart had been checked per the instructions.

During an interview on 5/3/2018 at 10:50 a.m., the administrator (ADM 3) reviewed the checklists and confirmed there was not clear evidence the carts had been checked on 4/12/2018 and 5/2/2018.