HospitalInspections.org

Based on complaint survey findings of Immediate Jeopardy, the facility Governing Body did not provide oversight of the hospital to ensure the protection of the safety of all patients thus failing to substantially comply with this condition.

The findings include:

A finding of Immediate Jeopardy was identified on 12/1/2020 regarding patient rights for care in a safe setting and protection of patients from Abuse.

An unlocked medication cart was accessed by patients of the facility and drugs were removed which could have resulted in injury, permanent harm or death to the patients involved. The facility failed to follow its policy and procedures for the investigation of the first allegation when reported, thus allowing a recurrence of a second report of patients removing medications from an unlocked medication cart. The facility failed to put into place a plan to prevent recurrence and promote patient safety.

On 12/1/2020, a Staff Member grabbed a patient by the arms and "shoved" the patient into a chair and began yelling at the patient. The facility investigated and and addressed the concern, however the facility has experienced multiple complaints concerning allegations of abuse of patients by staff. These allegations, which although may have been identified and addressed by the facility, demonstrated a recurring concern regarding systemic failure of the facility regarding protection of patients. The Governing Body of the facility has failed to provide oversight to the facility in recognizing and ensuring the facility establish sustainable plans to prevent recurrence of these concerns.

See the following tags:

A0115- Patient Rights- Condition of Participation -finding of Immediate Jeopardy
A0144- Patient Rights Care in a Safe Setting
A0145- Patient rights- Free from Abuse
A0263- QAPI -Condition of Participation
A0286- QAPI- Patient Safety
A0385- Nursing Services- Condition of Participation
A0398- Nursing Services- Nurses must adhere to facility Policies and Procedures
A0405- Nursing Services - Medication Administration - Basic Safe Practices
A0489- Pharmaceutical Services Condition of Participation
A0502- Secure Storage of Medications

The facility presented a plan of removal for the Immediate Jeopardy findings on 12/9/2020 at 12:20 p.m. After review and consideration by the Centers for Medicare and Medicaid Services and the State Agency, the plan was determined to be unacceptable and the facility remained in Immediate Jeopardy as of 12/9/2020 at 3:00 p.m.. The facility Leadership (Staff Members #1, 2, 3, 4, 8 and #13- Corporate Regional Regulatory Director) were notified at that time of the plan not being accepted and the Immediate Jeopardy remaining in effect.

Based on complaint survey findings of Immediate Jeopardy, the facility staff did not ensure the protection of the patients rights to a safe environment and to be free from all forms of abuse thus failing to substantially comply with this condition.

The findings include:

It was reported two patients having access to an unlocked medication cart, taking the medication Lamactil (Lamotrigine/Lamactil is a mood stabilizer medication) and crushing and "snorting" some of the medication. This occurred on 10/31/2020. It was reported by Patient #1 and #2 on 11/01/2020. The facility failed to conduct a full investigation and put a plan in place to prevent a reoccurrence. On 11/4/2020, Patient #1 and #2 were again able to access an unlocked medication cart and obtain the medication Seroquel (Seroquel- [quetiapine] is an antipsychotic medicine.) and crush the medications intending to "snort" the medication as was documented in the clinical records. There was no evidence the facility had begun to address this issue until 11/6/2020 and no formal/full investigation was conducted. Patient #1 was interviewed by the surveyor on 12/1/2020 regarding the allegation of taking the medications and stated the allegations were true. Patient #2 was no longer residing at the facility and could not be interviewed.

It was reported a staff member "grabbed" a patient by the arms and "shoved" the patient into a chair and yelled at the patient. This occurred on 12/1/2020. The facility suspended the staff member immediately pending the investigation. An investigation of the allegation was completed and determined it to be substantiated and the staff member was terminated. The facility presented the survey team with evidence of inservices conducted with staff of the Unit on which the event occurred. The inservices were "Power Struggles and Abuse and Neglect". Inservices were documented as being conducted on 12/4/2020. Inservices were then conducted with all direct care staff on 12/4, 12/5, 12/6, 12/7, 12/8 and 12/9/2020.

The survey team discussed with facility staff Members #1, 2, and #3 through out the survey the concerns regarding multiple complaints received by the state agency of ongoing patient care issues and abuse. The survey team discussed with the facility leadership these allegations demonstrate a systematic problem with regard to action plans previously developed, and the urgency and immediacy for the facility to review their systems in order to develop robust and sustainable plans to correct the concerns and prevent recurrence.

The facility presented a plan of removal for the Immediate Jeopardy findings on 12/9/2020 at 12:20 p.m. After review and consideration by the Centers for Medicare and Medicaid Services and the State Agency, the plan was determined to be unacceptable and the facility remained in Immediate Jeopardy as of 12/9/2020 at 3:00 p.m.. The facility Leadership (Staff Members #1, 2, 3, 4, 8 and #13- Corporate Regional Regulatory Director) were notified at that time of the plan not being accepted and the Immediate Jeopardy remaining in effect.



Please refer to tags A0144 and A0145.

Based on patient interview, staff interview, clinical record review, review of facility documents and during the course of a complaint investigation, it was determined the facility staff failed to ensure each patient received care in a safe setting. This had the potential to affect every patient residing at the facility.

The findings include:

Patient #1 and #2 were able to access an unlocked medication cart on two occasions removing Lamactil on 10/31/2020 and Seroquel on 11/4/2020, crushing the medications with the intent of "snorting" the medications. The patients self reported they had taken the medications.

After the first report, the facility failed to investigate and put a plan in place to prevent reoccurrence. There was no investigation or plan put in place to protect the patients and prevent future occurrence after the second report as well.

Patient #1 was admitted 8/24/2020. Contained in the clinical record was a "Daily RN (Registered Nurse) Assessment" note which documented, "11/1/2020 2000 (8:00 p.m.) Patient admitted to snorting crushed meds taken by peer from unit med cart on 10/21/2020..." On 11/4/2020 at 0400 (4:00 a.m.) it was documented, "Patient was observed acting strange during routine Q15 check (every fifteen minute checks). Pt (patient) was attempting to hide a med cup /c (with) a white substance that appeared crushed. Pt became agitated when staff confiscated ...Pt eventually stated that (patient) got Seroquel off med cart...Supervisor (name) aware of situation..." A "Medical Progress Note" dated 11/2/2020 evidenced, in part: "...(patient) reported to staff yesterday that (patient) obtained medications covertly from the med cart while a behavioral code was taking place on the unit along with another patient. (Patient) claims to have crushed and inhaled those medications. It is unclear what medications were obtained and of this event actually took place...an investigation is going to take place to review the validity of these claims..." On 11/4/2020 it was documented in the "Medical Progress Note: "...yesterday evening staff found (patient) with presumed medications that appear to be crushed. This was immediately confiscated from (patient)...an investigation is taking place..."

Patient #2 was admitted on 02/06/2020. The clinical record documented the Patient was on suicidal precautions. Review of the clinical record revealed a note dated 11/1/2020 at 2000 (8:00 p.m.) which documented, "(Patient name) admitted taking crushed meds from cart 10/31/2020 and snorting..." A "Medical Progress Note" dated 11/2/2020 evidenced, "...Yesterday (patient) reported to staff that (patient) stole medications from a cart on 10/31/2020. Afterwards (patient) claims to have crushed and inhaled them with another peer..." Further documentation provided by the facility evidenced on 11/6/2020 "the patient reported (patient) was in possession of contraband (medication) and (patient) turned in a powder substance to (patients) therapist in a small plastic bag with broken thermometer probes that appeared to have been used to attempt to snort the medication..."

The survey team requested the facility provide documentation of the investigation into both these reports.

On 11/30/2020 at approximately 12:15 p.m., Staff Member #1 (Quality) stated, "We cannot find any file that (Staff Member #7- former Risk Manager) or (Staff Member #4- Director of Nursing) had about this. (Staff Member #7) no longer works here." Staff Member #1 provided the survey team with documentation what evidenced the report had been filed and "Plan of action pending findings of investigation". Staff Member #1 and #2 (Chief Operating Officer) also provided the survey team with communication between leadership staff which discussed the allegation for the October 31 report. In one of the documents, Staff Member #7 wrote on November 2 that "immediate action to be taken in regards to nursing staff failing to follow the established procedure for locking and securing medication carts..." There was documentation presented that the facility had made an adjustment to their "rounds sheet" on 11/3/2020 and that "Medication Cart is secure" was added to this document. According to Staff Member #1, Leadership staff round on the units at least "once a shift" and utilize this document during those rounds. According to these "audit documents medication carts were found unlocked on various units on 11/3, 11/4, 11/5, and 11/6/2020. There was documentation that there were "Staff Meetings" on 11/5, 11/9, 11/10, and 11/11/2020 with a note that "Medication Carts being locked" was discussed.

On 11/30/2020 at 2:30 p.m., the surveyor interviewed Patient #1 in the presence of the patients therapist (Staff Member #5). Patient #1 stated, "I know why you're here. I figured I'd be talked to...the person from Social Services, I think her name was (name), came and talked to me about it...." The surveyor asked Patient #1 if they had taken the medications. Patient #1 stated, "I sure did. I stole the pills Seroquel and Lamactil. Yes I did it twice. I took the lamactil once and then another time I took the Seroquel. There was a code going on the unit and nobody was watching and I took them out of the unlocked med cart..."stole" is a relative term, I took my own pills from my drawer. I didn't take anybody else's medications....I was going to crush them and snort them..." The surveyor inquired as to whether anyone from the facility had interviewed (patient) about what (the patient) had admitted to and inquired as to whether Patient #2 knew (Staff Member #7- Risk Manager). Patient #2 stated, "Yes I know (name of Staff Member #7) and No; no one talked to me except the social services person and you now..." The surveyor asked Patient #2 if (the patient) was telling the truth about the report; and Patient #2 stated, "Yes Ma'am. I am telling the truth. I did indeed take the pills both times. I wish I hadn't, but I did. I am trying to do better. I know it was wrong..."

Further review of the documentation provided by the facility revealed that Staff Member #7 had stated in the document dated November 10, 2020, that the report (from 11/4/2020) "did not rise to a level III and this was prior to the camera review that did not show the patient accessing the medication cart. The original powdery substance in question was drywall dust..."

On 12/1/2020 at 8:45 a.m., the surveyor reviewed the timeline and findings with Staff Member #1 and expressed concern regarding the lack of investigation and intervention for both reports of medications being taken. The surveyor expressed concern that once reported on 11/1/2020, there was no plan put in place to prevent reoccurrence and on 11/4/2020 it was again reported that the patient had gotten medications from an unlocked medication cart. The surveyor also discussed the concerns that the facility did not reconcile medication carts at the time of either report to determine whether medications were missing and whether the substance was truly drywall dust or crushed medications.

On 12/1/2020 at 9:00 a.m., the survey team, after reviewing Appendix Q notified the State Agency Supervisory Staff of the findings/concerns for Immediate Jeopardy. The SA consulted the Centers for Medicare and Medicaid Services (CMS). On 12/1/2020 at 10:17 a.m., the facility Leadership (Staff Member #3- CEO, Staff Member #1- Quality, Staff Member #2- COO, and Staff Member #4 Chief Nursing Officer) were notified of the finding of Immediate Jeopardy and a plan of removal was requested.

At 12:30 p.m., on 12/1/2020, the surveyor conducted a follow-up interview with the therapist (Staff Member #5) of Patient #1. Staff Member #5 stated, "(Patient#1) is not very reliable, but (patient) shared with me the same information that was shared with you...(patient) would protect another peer, so (patient) would take responsibility for doing it and not "snitch" on another peer, and this behavior would not be out of character....I can't say whether its true or not, but I was told the same thing you were and it would be possible for (patient) to do that..."

The survey team interviewed Staff Member #6, Pharmacist on 12/1/2020 T 1:20 p.m.. Staff Member #6 stated, "The medication carts are filled on Tuesday and Fridays. We do a cart fill report that tells us how many (medications) to put in each cart for each (patient)....I was asked to look at the contents of the medication cup and it was a crushed substance, but did not look like medications, it had a tint to it...I wasn't told what drawer it came from, there are a lot of medication drawers..." When asked if Staff Member #6 had reconciled the cart at that time, the Staff Member stated, "No. That's a lot of medications drawers to look through." When asked if (Staff Member #6) had been notified that there were two reports, the staff member stated they were only asked to look at the crushed substance on one occasion. Staff Member #6 stated, "The tech who fills the cart never reported any doses missing and we were never informed a patient missed a dose of medication..."

On 12/1/2020 at 3:06 p.m., a plan of removal was presented by the facility. The plan of removal was as follows:

A0115 Patient Rights: Immediate Jeopardy Conditional Finding- The facility failed to meet one or more federal health, safety and/or Quality regulations. PLAN OF CORRECTION- Cumberland Hospital will correct the immediate jeopardy finding in 12/2/2020 with the corrective actions as stated to correct the conditional level finding under CMS Condition of Participation tag A144. PERSON RESPONSIBLE DISCUSSION- PERSON RESPONSIBLE: Chief Nursing Officer COMPLETION DATE 12-1-20. A144 PATIENT RIGHTS: CARE IN A SAFE SETTING- Observed: a medication cart was unlocked on unit 6B allowing a patient access to medications. A Patient accessed the unlocked cart on tow separate occasions, 10/31/2020 and 11/4/2020. Staff did not put a plan in place after becoming aware of the first incident; this allowed recurrence. The patient shared medication with another patient who was on suicide precautions. There is evidence that a serious adverse outcome occurred, or a serious adverse outcome is likely as a result of the identified noncompliance as follows: the patients were put at risk for adverse drug reaction, overdose, aggravation of underlying conditions, and/or death. There is a need for immediate action to include prevention of further occurrences, to maintain safety and prevent patient harm, injury or death. PLAN OF CORRECTION: -Day shift nurses were inserviced on medication cart storage, safety and keeping carts locked at all times by the Assistant Director of Nursing immediately upon receiving the immediate jeopardy notification. Further, all nurses arriving for shifts this evening and night will be provided with the same training prior to beginning their shifts. -The Assistant Director of Nursing and the Chief Nursing Officer completed unit rounds immediately upon receipt of the immediate jeopardy notification to assess the status of the medication carts. All carts were noted to be properly secured and in the locked position at the time of these observations. -The Chief Operating Officer revised the Observation Rounds Audit tool for Unit Coordinators and Nursing Supervisors to include observations of medication carts once per shift by a nurse manager. Observation status will include that unit medication carts were locked and properly secured upon observation. Occurrences of unlocked or improperly secured medication carts observed, will require immediate action by the manager performing the observation. Actions will include securing the cart, identifying the staff responsible for the error, and corrective action (up to disciplinary action) for the staff responsible for the cart at the time of the observation. - An additional corrective action for observed noncompliance of a secured (locked) medication cart. the pharmacist will be notified by the observing manager to perform an immediate reconciliation of the medications contained in the cart. If an observation of noncompliance is made during off-hours, the expectation is that the pharmacist on call is notified by the nursing supervisor and a reconciliation of the cart will be performed by the pharmacist during the next in-person shift. -Staff Nurses arriving for shifts after 12/1/2020 will be educated on medication cart safety prior to reporting to the unit for their scheduled shift until all staff nurses have received training. PERSON RESPONSIBLE DISCUSSION- PERSON RESPONSIBLE: Chief Nursing Officer. COMPLETION DATE: 12/1/2020.Quality Assessment and Performance Improvement- The facility's Director of Regulatory Compliance, Chief Operating Officer and Chief Executive Officer, as core members of the facility's Quality improvement committee, met on 12/7/2020 to discuss the immediate jeopardy findings identified by the agency. The core team retrospectively reviewed recent and ongoing corrective action plans and determined that while numerous improvements have been made in terms of incident identification, incident management and required reporting, the facility's actions to-date continue to require focus in order to achieve a desired reduction in occurrences of incidents involving Cumberland staff members. The team determined that in order for it's cumulative actions to be sustainable as long-term solutions, the facility's quality leaders need to expeditiously enhance the culture of quality and patient safety amongst its direct care staff members. The team further agreed to proceed with initiatives to facilitate changes in staff's perspectives, behaviors, and actions to fully align with the organization's commitment to quality patient care, reduction of serious incidents, and a culture of patient safety. The plan for comprehensive quality improvement and culture of staff accountability includes the following initiatives:
1. Intensive Staff Training: On 12/7/2020, the facility's CEO contacted UHS's Assistant Vice President of Clinical Training and Education for scheduling of an outside resource to provide intensive staff training to Cumberland's direct patient care staff. The request for training included topics related to preventing and managing power struggles with patients, milieu management, verbal de-escalation, and abuse and neglect recognition. The training is intended to extend staff's knowledge and expertise in managing challenging patient behaviors. The facility was assigned a corporate educator and course content was suggested. The facility has scheduled this education for all direct care staff commencing 12/11/2020 and to conclude not later than 12/31/2020. The intensive education plan further specifies this custom-designed curriculum, entitled "Prevention First Training" will be a required new-hire orientation course for all direct care staff as well as required annual training for existing staff continuing education and staff development.
A Program description of the "Prevention First" training specifies the curriculum as follows:
Training for non-direct care staff in de-escalation and crisis awareness.
Immediate training support to facilities and staff during COVID-19.
Provides-non classroom training for staff who are not required to have BMS training, but need skills in preventing and managing crisis situations.
Provides videos and a consistent message for staff and includes waiting room and nursing station scenarios as examples.
Can be used as remedial training for employees at any time.
Focuses on de-escalation, crisis prevention, and workplace violence prevention.
Cost effective and streamlined to prepare your entire organization to deal with the unpredictable reality of crisis.
2. Dual Reporting of Incidents: The quality improvement action plan will also include development of a process for dual reporting of serious incidents to the local social services agency as well as the state regulatory agency who has deemed oversight of the facility's compliance with CMS Conditions of Participation. The analysis of previously investigated incidents at our facility by the core quality team discovered that on multiple occasions the facility identified, investigated, managed and reported known incidents to the local social services agency but that the agency was reporting to the state oversight agency without the results of either their own or the facility's investigations or corrective actions, leading to a second regulatory investigation by the deemed state agency which were frequently disposed as "substantiated" complaints but with no deficient practice at the facility.
The facility will correct the redundancy in complaint investigations by having the Director of Quality and newly hired Director of Risk Management process the final results of internal investigations on reportable serious incidents jointly. The Director of risk Management will report serious incidents to the local Social Services Agency and to the regulatory Oversight agency ensuring that incident reporting is consistent, timely and contains evidence of a complete internal investigation, findings, evidence of standards compliance, and corrective actions taken, as applicable. The facility established this process by a planning meeting with Director of Quality, Director of risk Management, Chief Operating Officer on 12/8/2020.
3. Establishment of a Performance Improvement Executive Committee: The core team further addressed the identified deficiency in quality assessment conditions by establishing a Performance Improvement Executive Committee, which will provide explicit oversight of the facility's internal quality control initiatives, including but not limited to, the immediate improvement initiative to reduce the number of serious incidents directly involving patient care staff employed by the facility. The members of the performance Improvement executive Committee are Cumberland's CEO, COO, Director of Quality, Director of risk Management, CNO, Division Director of Clinical Services. The addition of the Division Director of Clinical Services on the committee will provide external expertise on regulatory matters to include the facility's sustained compliance with CMS Conditions of Participation. The committee will meet on a weekly basis. The agenda will include: compliance rates with direct care training requirements, remedial training needs, scheduling of external resources if needed, the current status of internal investigations, corrective actions taken as a result of substantiated investigations, monitoring of corrective action plans, and status of external reporting requirements as applicable.
The activities of the Performance Improvement executive Committee will further be summarized and reported to the facility's Governing Body as an agenda item at the Board's quarterly scheduled meeting.
4. Condition of Participation: Focused Mock Surveys
As additional reinforcement for the core team's commitment to correcting repeated quality concerns within the facility, the core team resolved to engage the Corporate Divisional Director of Clinical Services to perform quarterly mock survey's at the facility for a period of one year. The purpose of the mock surveys will specifically focus on assessing the facility's compliance with CMS Conditions of Participation, starting with the areas of concern, The first mock survey will be done beginning in 1st quarter of calendar year 2021. The Director's findings and observations will be communicated to the Performance Improvement executive Committee via action-item report. The report will be reviewed during the weekly meeting until the identified deficiencies are corrected. The facility will further include a plan for sustainability in response to the corrective actions taken.

On 12/1/2020 at 4:00 p.m., the survey team made rounds on the hospital units to verify the plan of removal had been implemented. The survey team did not identify any medication carts that were not secured and interviews with staff revealed they had received education regarding the facility policy/plan of ensuring medication carts were locked and secured at all times, and that patients were being observed to ensure their safety.

After review and consideration by the Centers for Medicare and Medicaid Services and the State Agency, the plan was determined to be unacceptable and the facility remained in Immediate Jeopardy as of 12/9/2020 at 3:00 p.m.. The facility Leadership (Staff Members #1, 2, 3, 4, 8 and #13- Corporate Regional Regulatory Director) were notified at that time of the plan not being accepted and the Immediate Jeopardy remaining in effect.

Based on staff interview, clinical record review, review of facility documents and during the course of a complaint investigation, it was determined the facility staff failed to ensure Patient #5 was free from abuse. Allegations of abuse have the potential to affect every patient residing at the facility.

The findings included:

On 12/1/2020, Patient #5 was "grabbed" by Staff Member #12 and pushed the patient down into a chair, as the staff member "yelled" at the patient.

Patient #5 was admitted to the facility on 8/28/2020. According to documentation in the clinical record, the following was evidenced: "12/1/2020 2220 (10:22 p.m.) PT (patient) had an incident w/a (with a) staff member when PT did not want to clean up (patient's) medical equipment after treatment in (patient's) room. Staff repeatedly prompted PT to cooperate and PT got aggressive and pushed staff w/ (with) both hands on staff's chest/shoulders. Staff almost fell over and physically sat patient down in chair and explained to (patient) that (patient) should not put hands on staff and push people over..."

According to the investigation conducted by Staff Member #8 (Risk Manager) the following was evidenced: "While UC (Unit Coordinator) was in the unit, the milieu was interrupted with a loud disruption of a staff member standing over the patient yelling at patient. UC went over to inquire as to what was happening and took patient to (patient's) room to talk with (patient) as to what had happened. Staff Member followed UC and patient to room and continued to argue with patient as (patient) attempted to talk with UC. UC sent staff member away from patient and room. Patient was tearful and stated (patient) was told by staff to pack up (patient's) breathing equipment. (Patient) states (patient) apparently had not packed it to staff's expectations as patient felt (they) were done packing it up and staff did not. (Patient) wanted the staff member to leave (patient's) room and admits to pushing the staff from (patient's) room. Patient stated staff grabbed the patient and "shoved (patient) into the chair and began to yell at (patient)". Incident was immediately reported to immediate senior supervisors. Staff member was pulled from the floor and sent home pending further investigation." Further documentation from the investigation revealed documentation of interviews with the UM (Unit Manager Staff Member #11) and Patient #5. Further documentation revealed: "Camera Review: The FMR (Facility Risk Manager) reviewed the camera incident via the camera system and found that at 16:45 (4:45 p.m.) the patient is not visible in (patient's) room but the staff member can be seen at the door way of the Pt's room. At 16:47 (4:47 p.m.) the pt. can be seen pushing the staff and shutting the door then the staff member grabs the patient and forces (patient) to sit down in a chair next to the door. At the same time the UM (Unit Manager/Coordinator) can be seen in what appears to be redirecting staff to let go of the patient which the staff member does. Next at 16:48 the patient goes back into (patient's) room (the camera cannot see what [patient] is doing) the staff member follows (patient) in, the UM walks over and appears to redirect staff out of the room and then verbalizes with the patient...Conclusion: Due to the evidence and statements above, this allegation has been found to be true...Follow-Up Action: The staff Member involved in this incident was suspended immediately and then terminated. Behavioral Techs (technicians) and RN's (Registered Nurses) for that shift are being retrained on power struggles- the training will be completed by 12/9/2020. The UM will be retrained on staff management which will be completed by 12/9/2020."

The statement of Patient #5 evidenced, in part: "I just finished my breathing treatment and was putting it up when I playfully pushed (name of staff member #12) and (staff member) got upset and pushed me into the chair and started to yell at me...."

The survey team conducted an follow-up interview with Staff Member #11 on 12/9/2020 at 10:00 a.m. The Staff Member recounted the event with the surveyors and stated, "I was behind d the nurses station and a heard a commotion that disrupted the milieu...I looked up and saw (Staff Member #12) standing over (Patient #5) yelling. I immediately walked over and I heard (Staff Member #12) say "Don't put your hands on me, I don't play like that"...I told (Staff Member) to step back and asked (Patient #5) to come with me so I could talk with (patient) privately in (patient's room). The (Staff Member) followed us into the room and was interrupting and I told (Staff Member) to leave. (Patient) was crying and I asked what happened...(patient said apparently (patient) had not done well putting up the equipment and that it had irritated (Staff). (Patient admitted to pushing staff out of (patient's) room and then said (Staff) grabbed (patient) by the arms and shoved (patient) into the chair...I immediately notified the supervisor and (Staff Member) was sent home pending an investigation....There have been grievances from a couple of the (patients) about (Staff Member #12) being rude and using inappropriate language , but it was not witnessed by anyone else. I did speak to (Staff Member #12) about the concerns and let (Staff Member) know that I was watching (Staff Member). I was not able to prove (Staff Member) had been rude, but I let (Staff Member) know that I was watching (Staff Member)...."

The facility presented the survey team with evidence of inservices conducted with staff of the Unit on which the event occurred. The inservices were "Power Struggles and Abuse and Neglect". Inservices were documented as being conducted on 12/4/2020. Inservices were then conducted with all direct care staff on 12/4, 12/5, 12/6, 12/7, 12/8 and 12/9/2020.

The survey team discussed with facility staff Members #1, 2, and #3 through out the survey the concerns regarding multiple complaints received by the state agency of ongoing patient care issues and abuse. The survey team discussed with the facility leadership these allegations demonstrate a systematic problem with regard to action plans previously developed, and the urgency and immediacy for the facility to review their systems in order to develop robust and sustainable plans to correct the concerns and prevent recurrence.

The facility presented a plan of removal for the Immediate Jeopardy findings on 12/9/2020 at 12:20 p.m.

The plan included the following:

On 12/1/2020 Cumberland Hospital took immediate action to investigate the alleged incident of staff abuse to a patient as follows: - The Unit Coordinator immediately responded to the area and removed the staff member from the vicinity of the patient. The Unit Coordinator interviewed the patient in (patient's) room to determine the cause of the disruption. The patient alleged that a staff member had abused (patient) by grabbing (patient), pushing (patient) into a chair and yelling at (patient). - Per Cumberland policy on Suspected Abuse and Neglect of a Patient, the Unit Coordinator notified the senior supervisor on duty of the occurrence and suspended the employee pending further investigation of the allegation. The employee immediately left the facility and did not work another shift at the facility. - The attending physician and the patient's legal guardian were notified of the incident. The associated allegation was entered into the facility's internal incident reporting system for further follow-up and investigation.
In the morning of 12/2/2020, the facility's risk Manager was notified by the Assistant Director of Nursing of the allegation of abuse and suspension of the employee. The Risk Manager completed the investigation and determined that the allegation of staff abuse to a patient was substantiated. Elements of the investigation included the following: A camera review of the incident. Interviews with the patient, unit coordinator and other staff members present on the unit at the time of the occurrence. The Assistant Director of Nursing initiated disciplinary action for the employee based on the substantiated findings noted by the Director of Risk Management. The Director of Risk Management notified New Kent County Social Services of the incident of substantiated patient abuse.
On 12/4/2020 based on the substantiated findings, the employee was terminated. From 12/2 to (employee) termination on 12/4/2020, the employee did not have any contact with Cumberland patients following the incident with the complaining patient.
To immediately prevent further occurrences of patient abuse and to maintain patient safety on patient care units, evening shift patient care staff were re-educated on "Avoiding Power Struggles" and "abuse and Neglect" by the Assistant Director of Nursing upon receiving the immediate jeopardy notification. Further all nurses arriving for shifts subsequent to jeopardy notification will be provided with the same training prior to beginning their shifts.
Quality Assessment and Performance Improvement- The facility's Director of Regulatory Compliance, Chief Operating Officer and Chief Executive Officer, as core members of the facility's Quality improvement committee, met on 12/7/2020 to discuss the immediate jeopardy findings identified by the agency. The core team retrospectively reviewed recent and ongoing corrective action plans and determined that while numerous improvements have been made in terms of incident identification, incident management and required reporting, the facility's actions to-date continue to require focus in order to achieve a desired reduction in occurrences of incidents involving Cumberland staff members. The team determined that in order for it's cumulative actions to be sustainable as long-term solutions, the facility's quality leaders need to expeditiously enhance the culture of quality and patient safety amongst its direct care staff members. The team further agreed to proceed with initiatives to facilitate changes in staff's perspectives, behaviors, and actions to fully align with the organization's commitment to quality patient care, reduction of serious incidents, and a culture of patient safety. The plan for comprehensive quality improvement and culture of staff accountability includes the following initiatives:
1. Intensive Staff Training: On 12/7/2020, the facility's CEO contacted UHS's Assistant Vice President of Clinical Training and Education for scheduling of an outside resource to provide intensive staff training to Cumberland's direct patient care staff. The request for training included topics related to preventing and managing power struggles with patients, milieu management, verbal de-escalation, and abuse and neglect recognition. The training is intended to extend staff's knowledge and expertise in managing challenging patient behaviors. The facility was assigned a corporate educator and course content was suggested. The facility has scheduled this education for all direct care staff commencing 12/11/2020 and to conclude not later than 12/31/2020. The intensive education plan further specifies this custom-designed curriculum, entitled "Prevention First Training" will be a required new-hire orientation course for all direct care staff as well as required annual training for existing staff continuing education and staff development.
A Program description of the "Prevention First" training specifies the curriculum as follows:
Training for non-direct care staff in de-escalation and crisis awareness.
Immediate training support to facilities and staff during COVID-19.
Provides-non classroom training for staff who are not required to have BMS training, but need skills in preventing and managing crisis situations.
Provides videos and a consistent message for staff and includes waiting room and nursing station scenarios as examples.
Can be used as remedial training for employees at any time.
Focuses on de-escalation, crisis prevention, and workplace violence prevention.
Cost effective and streamlined to prepare your entire organization to deal with the unpredictable reality of crisis.
2. Dual Reporting of Incidents: The quality improvement action plan will also include development of a process for dual reporting of serious incidents to the local social services agency as well as the state regulatory agency who has deemed oversight of the facility's compliance with CMS Conditions of Participation. The analysis of previously investigated incidents at our facility by the core quality team discovered that on multiple occasions the facility identified, investigated, managed and reported known incidents to the local social services agency but that the agency was reporting to the state oversight agency without the results of either their own or the facility's investigations or corrective actions, leading to a second regulatory investigation by the deemed state agency which were frequently disposed as "substantiated" complaints but with no deficient practice at the facility.
The facility will correct the redundancy in complaint investigations by having the Director of Quality and newly hired Director of Risk Management process the final results of internal investigations on reportable serious incidents jointly. The Director of risk Management will report serious incidents to the local Social Services Agency and to the regulatory Oversight agency ensuring that incident reporting is consistent, timely and contains evidence of a complete internal investigation, findings, evidence of standards compliance, and corrective actions taken, as applicable. The facility established this process by a planning meeting with Director of Quality, Director of risk Management, Chief Operating Officer on 12/8/2020.
3. Establishment of a Performance Improvement Executive Committee: The core team further addressed the identified deficiency in quality assessment conditions by establishing a Performance Improvement Executive Committee, which will provide explicit oversight of the facility's internal quality control initiatives, including but not limited to, the immediate improvement initiative to reduce the number of serious incidents directly involving patient care staff employed by the facility. The members of the performance Improvement executive Committee are Cumberland's CEO, COO, Director of Quality, Director of risk Management, CNO, Division Director of Clinical Services. The addition of the Division Director of Clinical Services on the committee will provide external expertise on regulatory matters to include the facility's sustained compliance with CMS Conditions of Participation. The committee will meet on a weekly basis. The agenda will include: compliance rates with direct care training requirements, remedial training needs, scheduling of external resources if needed, the current status of internal investigations, corrective actions taken as a result of substantiated investigations, monitoring of corrective action plans, and status of external reporting requirements as applicable.
The activities of the Performance Improvement executive Committee will further be summarized and reported to the facility's Governing Body as an agenda item at the Board's quarterly scheduled meeting.
4. Condition of Participation: Focused Mock Surveys
As additional reinforcement for the core team's commitment to correcting repeated quality concerns within the facility, the core team resolved to engage the Corporate Divisional Director of Clinical Services to perform quarterly mock survey's at the facility for a period of one year. The purpose of the mock surveys will specifically focus on assessing the facility's compliance with CMS Conditions of Participation, starting with the areas of concern, The first mock survey will be done beginning in 1st quarter of calendar year 2021. The Director's findings and observations will be communicated to the Performance Improvement executive Committee via action-item report. The report will be reviewed during the weekly meeting until the identified deficiencies are corrected. The facility will further include a plan for sustainability in response to the corrective actions taken.

After review and consideration by the Centers for Medicare and Medicaid Services and the State Agency, the plan was determined to be unacceptable and the facility remained in Immediate Jeopardy as of 12/9/2020 at 3:00 p.m.. The facility Leadership (Staff Members #1, 2, 3, 4, 8 and #13- Corporate Regional Regulatory Director) were notified at that time of the plan not being accepted and the Immediate Jeopardy remaining in effect.

Based on findings of Immediate Jeopardy during a complaint investigation, the facility staff did not ensure an effective quality program was developed and implemented to track, monitor and develop sustainable action plans to prevent continued patient care and quality concerns regarding patient rights and the health and safety of patients residing at the facility thus failing to substantially comply with this condition.

The findings include:

Throughout the previous months, the facility has had multiple incidents of concerns involving patient rights and patient care issues which have resulted in multiple unannounced complaint investigations, and findings of non-compliance in Conditions of Participation for Patient Rights and Quality Assurance and Performance Improvement. Action Plans developed by the facility have not been sustained as evidenced by the current finding from the complaint investigation of 12/1/2020 of Immediate Jeopardy and associated non-compliance for the Conditions of participation for Patient Rights, Governing Body, Nursing Services, and Pharmaceutical Services as well as the repeated allegation of abuse to patients by staff.

The facility presented a plan of removal for the identified Immediate Jeopardy findings on 12/1/2020, however, the additional concern of Abuse was identified which resulted in the facility remaining in Immediate Jeopardy. The facility again presented a plan of removal on 12/9/2020 which was not considered an acceptable plan. As of 12/9/2020, the facility remained in Immediate Jeopardy.

The facility has experienced multiple complaints of allegations of abuse by employees to patients in the previous months which demonstrated a systematic failure by the facility to implement a sustainable plan in order to prevent the recurrent allegations of abuse.

Please refer to A0286 for further information.

Based on staff interview, patient interview, clinical record review, review of facility documents and during the course of a complaint investigation, it was determined the facility staff failed to ensure the Quality Program monitored and tracked adverse patient occurrences and demonstrated plans to show improvement in these areas.

The findings included:

Multiple areas of concerns were identified during the complaint investigation resulting in an immediate jeopardy finding. The facility had two reports of patients accessing unlocked medication carts and talking medications which were not investigated.

Also, multiple complaints have been received over the past months requiring numerous complaint investigations by the state agency. This demonstrates an concern regarding a systematic failure of the facility to implement a sustainable plan to prevent these concerns.

Patient #1 and #2 self reported they had been able to access unlocked medication carts and take medications from the cart of two occasions; 10/31/2020 and 11/4/2020. After the first occurrence, there was no investigation of plan of action developed to prevent reoccurrence and the patient's again accessed the cart and took medications.

According to documents presented to the survey team, the CNO (Chief Nursing Officer Report October 2020) stated, "inservicing on medication administration and security will be completed in month of November for all nurses"...there was no date on this document to establish when it was written/submitted, although in an interview with Staff Member #1 (Quality) on 12/1/2020 at 8:45 a.m., the Staff Member stated, "I don't know exactly when this was done but it is due to the CEO by the tenth of November..."

On November 2, 2020 per an email document provided by the facility, the medication carts being locked was discussed. The "Medication cart is Secured" was added to the "Leadership Rounds Audit" sheet which, according to Staff Member #1, is completed once a shift by Leadership staff on rounds. The final document was given for use on November 3,2020.

After the addition of the medication cart check to the rounds sheet, medication carts were found unlocked on 11/3, 11/4, 11/5, and 11/6/2020 during the rounds. Meetings for nursing staff regarding medication cart safety and patient monitoring were not started until 11/9/2020, however there was one unit which had a meeting on 11/5/2020 and handwritten in the corner of the copy of the agenda sheet presented to the survey team was "*med carts locked at all X's (times)". The survey team was not provided with any evidence of robust inservicing, training or progressive discipline regarding the serious nature of the reports of patients having access to unlocked medication carts and patient monitoring.

When interviewed on 12/1/2020 at approximately 2:00 p.m., Staff Member #4 (CNO) was asked what occurred if leadership found carts unlocked on rounds. Staff Member #4 stated, "The nurse is spoken to and the cart immediately secured." When asked whether there was documentation of when staff were "spoken to" in terms of initiating progressive discipline for failure to follow safety and hospital policy, staff member #4 stated, "It should be done."

The survey team discussed with Staff Member #1 and #4 that the information provided for the "meetings" held with nursing staff did not reflect a robust education for the staff regarding the responsibilities of patient safety, basic medication practices, patient monitoring, as well as potential consequences for failure to follow hospital policy and procedures.

The concerns were reviewed with the facility Leadership staff (Staff Members #1, 2, 3, 4, and #8) on 12/1/2020 at 4:20 p.m.

On 12/1/2020, Patient #5 was "grabbed" by Staff Member #12 and pushed down into a chair, as the staff member "yelled" at the patient.

According to the investigation conducted by Staff Member #8 (Risk Manager) the following was evidenced: "While UC (Unit Coordinator) was in the unit, the milieu was interrupted with a loud disruption of a staff member standing over the patient yelling at patient. UC went over to inquire as to what was happening and took patient to (patient's) room to talk with (patient) as to what had happened. Staff Member followed UC and patient to room and continued to argue with patient as (patient) attempted to talk with UC. UC sent staff member away from patient and room. Patient was tearful and stated (patient) was told by staff to pack up (patient's) breathing equipment. (Patient) states (patient) apparently had not packed it to staff's expectations as patient felt (they) were done packing it up and staff did not. (Patient) wanted the staff member to leave (patient's) room and admits to pushing the staff from (patient's) room. Patient stated staff grabbed the patient and "shoved (patient) into the chair and began to yell at (patient)". Incident was immediately reported to immediate senior supervisors. Staff member was pulled from the floor and sent home pending further investigation." Further documentation from the investigation revealed documentation of interviews with the UM (Unit Manager Staff Member #11) and Patient #5. Further documentation revealed: "Camera Review: The FMR (Facility Risk Manager) reviewed the camera incident via the camera system and found that at 16:45 (4:45 p.m.) the patient is not visible in (patient's) room but the staff member can be seen at the door way of the Pt's room. At 16:47 (4:47 p.m.) the pt. can be seen pushing the staff and shutting the door then the staff member grabs the patient and forces (patient) to sit down in a chair next to the door. At the same time the UM (Unit Manager/Coordinator) can be seen in what appears to be redirecting staff to let go of the patient which the staff member does. Next at 16:48 the patient goes back into (patient's) room (the camera cannot see what [patient] is doing) the staff member follows (patient) in, the UM walks over and appears to redirect staff out of the room and then verbalizes with the patient...Conclusion: Due to the evidence and statements above, this allegation has been found to be true...Follow-Up Action: The staff Member involved in this incident was suspended immediately and then terminated. Behavioral Techs (technicians) and RN's (Registered Nurses) for that shift are being retrained on power struggles- the training will be completed by 12/9/2020. The UM will be retrained on staff management which will be completed by 12/9/2020."

The facility presented the survey team with evidence of inservices conducted with staff of the Unit on which the event occurred. The inservices were "Power Struggles and Abuse and Neglect". Inservices were documented as being conducted on 12/4/2020. Inservices were then conducted with all direct care staff on 12/4, 12/5, 12/6, 12/7, 12/8 and 12/9/2020.

The survey team discussed with facility staff Members #1, 2, and #3 through out the survey the concerns regarding multiple complaints received by the state agency of ongoing patient care issues and abuse. The survey team discussed with the facility leadership these allegations demonstrate a systematic problem with regard to action plans previously developed, and the urgency and immediacy for the facility to review their systems in order to develop robust and sustainable plans to correct the concerns and prevent recurrence.

The facility presented a plan of removal for the Immediate Jeopardy findings on 12/9/2020 at 12:20 p.m. After review and consideration by the Centers for Medicare and Medicaid Services and the State Agency, the plan was determined to be unacceptable and the facility remained in Immediate Jeopardy as of 12/9/2020 at 3:00 p.m.. The facility Leadership (Staff Members #1, 2, 3, 4, 8 and #13- Corporate Regional Regulatory Director) were notified at that time of the plan not being accepted and the Immediate Jeopardy remaining in effect.

Based on staff interview, patient interview, clinical record review, review of facility documents and during the course of a complaint investigation, the facility staff did not ensure Nursing care was provided in a safe environment and that patients were provided adequate supervision to prevent harm/potential harm thus failing to substantially comply with this condition.

The findings include:

On 10/31/2020 Patient #1 and #2 were able to access an unlocked medication cart, thus taking medications. Again on 11/4/2020, Patient #1 accessed an unlocked medication cart and took medications. The facility staff failed to follow policy and procedure and basic safe medication practices in keeping medication carts locked and patients under observation to ensure safety.

This resulted in an Immediate Jeopardy finding under Patient Rights- Care in a safe setting.

Please refer to:
A0398, A0405, and A0144 further information.

Based on staff interview, patient interview, clinical record review, review of facility documents and during the course of a complaint investigation, it was determined the facility staff failed to ensure nursing staff adhered to hospital policies and procedures for the safe storage of medications and the monitoring of patients.

The findings included:

On 10/31/2020 Patient #1 and #2 gained access to un unsecured medication cart during what was described as a "behavioral outburst" by another patient without staff knowledge Again, on 11/4/2020, a medication cart was left unsecured and Patient #1 again was able to access the cart and take medications without staff knowledge.

Patient #1 was admitted 8/24/2020. Contained in the clinical record was a "Daily RN (Registered Nurse) Assessment" note which documented, "11/1/2020 2000 (8:00 p.m.) Patient admitted to snorting crushed meds taken by peer from unit med cart on 10/21/2020..." On 11/4/2020 at 0400 (4:00 a.m.) it was documented, "Patient was observed acting strange during routine Q15 check (every fifteen minute checks). Pt (patient) was attempting to hide a med cup /c (with) a white substance that appeared crushed. Pt became agitated when staff confiscated ...Pt eventually stated that (patient) got Seroquel off med cart...Supervisor (name) aware of situation..." A "Medical Progress Note" dated 11/2/2020 evidenced, in part: "...(patient) reported to staff yesterday that (patient) obtained medications covertly from the med cart while a behavioral code was taking place on the unit along with another patient. (Patient) claims to have crushed and inhaled those medications. It is unclear what medications were obtained and of this event actually took place...an investigation is going to take place to review the validity of these claims..." On 11/4/2020 it was documented in the "Medical Progress Note: "...yesterday evening staff found (patient) with presumed medications that appear to be crushed. This was immediately confiscated from (patient)...an investigation is taking place..."

Patient #2 was admitted on 02/06/2020. The clinical record documented the Patient was on suicidal precautions. Review of the clinical record revealed a note dated 11/1/2020 at 2000 (8:00 p.m.) which documented, "(Patient name) admitted taking crushed meds from cart 10/31/2020 and snorting..." A "Medical Progress Note" dated 11/2/2020 evidenced, "...Yesterday (patient) reported to staff that (patient) stole medications from a cart on 10/31/2020. Afterwards (patient) claims to have crushed and inhaled them with another peer..." Further documentation provided by the facility evidenced on 11/6/2020 "the patient reported (patient) was in possession of contraband (medication) and (patient) turned in a powder substance to (patients) therapist in a small plastic bag with broken thermometer probes that appeared to have been used to attempt to snort the medication..."

The facility policy for "Medication Administration" was reviewed and evidenced, In part: "Storage: 19. All medications will be stored in the medication cart or locked cabinet...22. The medication cart/room will be kept locked AT ALL times when not in use by the nurse..." Under "Milieu Management" "15 (fifteen) minute observation rounds must be completed on all patients every 15 minutes...during CODE situations someone must be assigned to monitor patient safety, especially of those not involved in the current situation..."

On 11/30/2020 at 2:30 p.m., the surveyor interviewed Patient #1 in the presence of the patients therapist (Staff Member #5). Patient #1 stated, "I know why you're here. I figured I'd be talked to...the person from Social Services, I think her name was (name), came and talked to me about it...." The surveyor asked Patient #1 if they had taken the medications. Patient #1 stated, "I sure did. I stole the pills Seroquel (an antipsychotic) and Lamactil (a mood stabilizer). Yes I did it twice. I took the lamactil once and then another time I took the Seroquel. There was a code going on the unit and nobody was watching and I took them out of the unlocked med cart..."stole" is a relative term, I took my own pills from my drawer. I didn't take anybody else's medications....I was going to crush them and snort them..." The surveyor asked Patient #2 if (the patient) was telling the truth about the report; and Patient #2 stated, "Yes Ma'am. I am telling the truth. I did indeed take the pills both times. I wish I hadn't, but I did. I am trying to do better. I know it was wrong..."

In an interview with Staff Member #9, a Registered Nurse on 12/1/2020 at 3:20 p.m., the staff member stated, "Medication carts are to be locked at all times and never left unattended...all patients are to be checked every fifteen minutes but staff are responsible for knowing where they are at all times..."

Concerns were addressed with Facility Leadership (Staff Member#1) on 12/1/2020 at 8:45 a.m. and again at 4:20 p.m. with Staff Members #1,2,3,4, and 8.

Based on staff interview, patient interview, clinical record review, review of facility documents and during the course of a complaint investigation, it was determined the facility staff failed to ensure staff followed basic safe practices for medication administration. The Nursing staff failed to ensure medication carts were locked at all times to prevent unauthorized access. This affected two patients, Patient #1 and #2, but had the potential to affect all patients at the facility.

The findings included:

Patient #1 and #2 were able to access the medication cart which was left unlocked on two separate occasions taking two different medications. On 10/31/2020 the medication Lamactil was taken, and on 11/4/2020, the medication Seroquel was taken.

Patient #1 was admitted 8/24/2020. Contained in the clinical record was a "Daily RN (Registered Nurse) Assessment" note which documented, "11/1/2020 2000 (8:00 p.m.) Patient admitted to snorting crushed meds taken by peer from unit med cart on 10/21/2020..." On 11/4/2020 at 0400 (4:00 a.m.) it was documented, "Patient was observed acting strange during routine Q15 check (every fifteen minute checks). Pt (patient) was attempting to hide a med cup /c (with) a white substance that appeared crushed. Pt became agitated when staff confiscated ...Pt eventually stated that (patient) got Seroquel off med cart...Supervisor (name) aware of situation..." A "Medical Progress Note" dated 11/2/2020 evidenced, in part: "...(patient) reported to staff yesterday that (patient) obtained medications covertly from the med cart while a behavioral code was taking place on the unit along with another patient. (Patient) claims to have crushed and inhaled those medications. It is unclear what medications were obtained and of this event actually took place...an investigation is going to take place to review the validity of these claims..." On 11/4/2020 it was documented in the "Medical Progress Note: "...yesterday evening staff found (patient) with presumed medications that appear to be crushed. This was immediately confiscated from (patient)...an investigation is taking place..."

Patient #2 was admitted on 02/06/2020. The clinical record documented the Patient was on suicidal precautions. Review of the clinical record revealed a note dated 11/1/2020 at 2000 (8:00 p.m.) which documented, "(Patient name) admitted taking crushed meds from cart 10/31/2020 and snorting..." A "Medical Progress Note" dated 11/2/2020 evidenced, "...Yesterday (patient) reported to staff that (patient) stole medications from a cart on 10/31/2020. Afterwards (patient) claims to have crushed and inhaled them with another peer..." Further documentation provided by the facility evidenced on 11/6/2020 "the patient reported (patient) was in possession of contraband (medication) and (patient) turned in a powder substance to (patients) therapist in a small plastic bag with broken thermometer probes that appeared to have been used to attempt to snort the medication..."

The facility policy for "Medication Administration" was reviewed and evidenced, In part: "Storage: 19. All medications will be stored in the medication cart or locked cabinet...22. The medication cart/room will be kept locked AT ALL times when not in use by the nurse..." Under "Milieu Management" "15 (fifteen) minute observation rounds must be completed on all patients every 15 minutes...during CODE situations someone must be assigned to monitor patient safety, especially of those not involved in the current situation..." According to "audit documents" which were performed by facility leadership, medication carts were found unlocked on various units on 11/3, 11/4, 11/5, and 11/6/2020.

On 11/30/2020 at 2:30 p.m., the surveyor interviewed Patient #1 in the presence of the patients therapist (Staff Member #5). Patient #1 stated, "I know why you're here. I figured I'd be talked to...the person from Social Services, I think her name was (name), came and talked to me about it...." The surveyor asked Patient #1 if they had taken the medications. Patient #1 stated, "I sure did. I stole the pills Seroquel (an antipsychotic) and Lamactil (a mood stabilizer). Yes I did it twice. I took the lamactil once and then another time I took the Seroquel. There was a code going on the unit and nobody was watching and I took them out of the unlocked med cart..."stole" is a relative term, I took my own pills from my drawer. I didn't take anybody else's medications....I was going to crush them and snort them..." The surveyor asked Patient #2 if (the patient) was telling the truth about the report; and Patient #2 stated, "Yes Ma'am. I am telling the truth. I did indeed take the pills both times. I wish I hadn't, but I did. I am trying to do better. I know it was wrong..."

In an interview with Staff Member #9, a Registered Nurse on 12/1/2020 at 3:20 p.m., the staff member stated, "Medication carts are to be locked at all times and never left unattended...all patients are to be checked every fifteen minutes but staff are responsible for knowing where they are at all times..."

Concerns were addressed with Facility Leadership (Staff Member#1) on 12/1/2020 at 8:45 a.m. and again at 4:20 p.m. with Staff Members #1,2,3,4, and 8.

Based on staff interview, patient interview, clinical record review, facility document review and during the course of a complaint investigation, the facility did not ensure Pharmacy services were provided that ensured the safety of all patients thus failing to substantially comply with this condition.

The findings include:

On 10/31/2020 and 11/4/2020 medication carts were left unlocked and accessed by two patients (Patient #1 and #2). There was no reconciliation of medications by the facility pharmacy services to determine the actual medications taken and whether other medications could potentially be missing.

This resulted in a finding of Immediate Jeopardy for the rights of patients to receive care in a safe setting.

Please refer to A0115, A0144, A0345, A0398, A405 and A502 for further information.

Based on staff interview, patient interview, clinical record review, facility document review and during the course of a complaint investigation, it was determined the facility staff failed to ensure the safe storage of medications and when a reported unauthorized access occurred, the facility failed to ensure medications were reconciled to determine the actual medications that were taken, and whether other medications were potentially missing. Also the facility failed to ensure when medication carts were found to be unlocked, that medications had not been removed.

The findings included:

Patient #1 and #2 reportedly accessed an unlocked medication cart on 10/31/2020 and again on 11/4/2020 removing medications. There was no reconciliation of medications when the report was received to determine whether medications were missing and the actual medications taken. There were also other occasions when medication carts were found unlocked and no check was done to see if any medications were missing.

Patient #1 was admitted 8/24/2020. Contained in the clinical record was a "Daily RN (Registered Nurse) Assessment" note which documented, "11/1/2020 2000 (8:00 p.m.) Patient admitted to snorting crushed meds taken by peer from unit med cart on 10/21/2020..." On 11/4/2020 at 0400 (4:00 a.m.) it was documented, "Patient was observed acting strange during routine Q15 check (every fifteen minute checks). Pt (patient) was attempting to hide a med cup /c (with) a white substance that appeared crushed. Pt became agitated when staff confiscated ...Pt eventually stated that (patient) got Seroquel off med cart...Supervisor (name) aware of situation..." A "Medical Progress Note" dated 11/2/2020 evidenced, in part: "...(patient) reported to staff yesterday that (patient) obtained medications covertly from the med cart while a behavioral code was taking place on the unit along with another patient. (Patient) claims to have crushed and inhaled those medications. It is unclear what medications were obtained and of this event actually took place...an investigation is going to take place to review the validity of these claims..." On 11/4/2020 it was documented in the "Medical Progress Note: "...yesterday evening staff found (patient) with presumed medications that appear to be crushed. This was immediately confiscated from (patient)...an investigation is taking place..."

Patient #2 was admitted on 02/06/2020. The clinical record documented the Patient was on suicidal precautions. Review of the clinical record revealed a note dated 11/1/2020 at 2000 (8:00 p.m.) which documented, "(Patient name) admitted taking crushed meds from cart 10/31/2020 and snorting..." A "Medical Progress Note" dated 11/2/2020 evidenced, "...Yesterday (patient) reported to staff that (patient) stole medications from a cart on 10/31/2020. Afterwards (patient) claims to have crushed and inhaled them with another peer..." Further documentation provided by the facility evidenced on 11/6/2020 "the patient reported (patient) was in possession of contraband (medication) and (patient) turned in a powder substance to (patients) therapist in a small plastic bag with broken thermometer probes that appeared to have been used to attempt to snort the medication..."

The survey team requested the facility provide documentation of the investigation into both these reports.

On 11/30/2020 at approximately 12:15 p.m., Staff Member #1 (Quality) stated, "We cannot find any file that (Staff Member #7- former Risk Manager) or (Staff Member #4- Director of Nursing) had about this. (Staff Member #7) no longer works here." There was documentation presented that the facility had made an adjustment to their "rounds sheet" on 11/3/2020 and that "Medication Cart is secure" was added to this document. According to Staff Member #1, Leadership staff round on the units at least "once a shift" and utilize this document during those rounds. According to these "audit documents medication carts were found unlocked on various units on 11/3, 11/4, 11/5, and 11/6/2020.

On 11/30/2020 at 2:30 p.m., the surveyor interviewed Patient #1 in the presence of the patients therapist (Staff Member #5). Patient #1 stated, "I know why you're here. I figured I'd be talked to...the person from Social Services, I think her name was (name), came and talked to me about it...." The surveyor asked Patient #1 if they had taken the medications. Patient #1 stated, "I sure did. I stole the pills Seroquel and Lamactil. Yes I did it twice. I took the lamactil once and then another time I took the Seroquel. There was a code going on the unit and nobody was watching and I took them out of the unlocked med cart..."stole" is a relative term, I took my own pills from my drawer. I didn't take anybody else's medications....I was going to crush them and snort them..." The surveyor inquired as to whether anyone from the facility had interviewed (patient) about what (the patient) had admitted to and inquired as to whether Patient #2 knew (Staff Member #7- Risk Manager). Patient #2 stated, "Yes I know (name of Staff Member #7) and No; no one talked to me except the social services person and you now..." The surveyor asked Patient #2 if (the patient) was telling the truth about the report; and Patient #2 stated, "Yes Ma'am. I am telling the truth. I did indeed take the pills both times. I wish I hadn't, but I did. I am trying to do better. I know it was wrong..."

Further review of the documentation provided by the facility revealed that Staff Member #7 had stated in the document dated November 10, 2020, that the report (from 11/4/2020) "did not rise to a level III and this was prior to the camera review that did not show the patient accessing the medication cart. The original powdery substance in question was drywall dust..."

On 12/1/2020 at 8:45 a.m., the surveyor reviewed the timeline and findings with Staff Member #1 and expressed concern regarding the lack of investigation and intervention for both reports of medications being taken. The surveyor expressed concern that once reported on 11/1/2020, there was no plan put in place to prevent reoccurrence and on 11/4/2020 it was again reported that the patient had gotten medications from an unlocked medication cart. The surveyor also discussed the concerns that the facility did not reconcile medication carts at the time of either report to determine whether medications were missing and whether the substance was truly drywall dust or crushed medications.

The survey team interviewed Staff Member #6, Pharmacist on 12/1/2020 T 1:20 p.m.. Staff Member #6 stated, "The medication carts are filled on Tuesday and Fridays. We do a cart fill report that tells us how many (medications) to put in each cart for each (patient)....I was asked to look at the contents of the medication cup and it was a crushed substance, but did not look like medications, it had a tint to it...I wasn't told what drawer it came from, there are a lot of medication drawers..." When asked if Staff Member #6 had reconciled the cart at that time, the Staff Member stated, "No. That's a lot of medications drawers to look through." When asked if (Staff Member #6) had been notified that there were two reports, the staff member stated they were only asked to look at the crushed substance on one occasion. Staff Member #6 stated, "The tech who fills the cart never reported any doses missing and we were never informed a patient missed a dose of medication..."

The survey team discussed the concerns with facility Leadership on 12/1/2020 at 8:45 a.m. (Staff Member #1) and at 10:17 a.m. (Staff Members #1, 2, 3, and 4.) The concerns were again reviewed on 12/1/2020 qt 4:20 p.m.