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Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to maintain a Governing Body that was effectively managing the facility. Observations and interviews revealed when a patient presented to the Emergency Department (ED) with a behavioral health concern, the patient was taken to an "Evaluation Room," a 199 square foot room with six chairs. Interview and record review revealed patients (male and female) were spending more than twenty-four hours in the Evaluation Room when inpatient behavioral health beds were not available or when the patient did not have available transportation from the facility. Subsequently, patients were sleeping on the floor or in chairs in the room. In addition, interviews with patients and staff from other facilities revealed the facility failed to provide meals/snacks for Patients #1, #2, and #3; failed to provide medications to Patients #1, #2, and #5; and failed to provide incontinence care for Patient #1 while they were patients in the Evaluation Room for more than twenty-four (24) hours.

In addition, the facility failed to ensure patients who required precautions due to multi-drug resistant infections were receiving precautions to prevent the spread of infection. Observations and record review revealed eight (8) patients (Patient #4 and seven (7) unsampled patients) required contact precautions; however, precautions were not implemented to prevent the spread of the resistant infections. Further, observation of Patient #6 revealed contact precautions were required to be in place; however, staff was observed not implementing the contact precautions.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Chief Executive Officer (CEO), appointed by the Governing Body, was effectively managing the facility. Observation and interviews revealed when patients presented to the Emergency Department with a behavioral health concern, they were taken to the Evaluation Room, a 199 square foot room with six chairs. Interview and record review revealed patients (male and female) were spending more than twenty-four hours in the Evaluation Room, sleeping on the floor or in chairs, and were not routinely receiving food or medications.

In addition, the facility failed to ensure patients who required precautions due to drug-resistant infections were receiving precautions. Observations and record review revealed eight (8) patients required contact precautions; however, precautions had not been implemented. Further, observation of one patient revealed contact precautions were in place; however, staff was observed not implementing the precautions.

The findings include:

Review of the facility's policy titled "Organizational Quality Management Plan," not dated, revealed the CEO was responsible for implementing effective communication mechanisms between and among hospital departments, the Medical Staff, Administration, Medical Staff Officers, and the Board of Trustees [Governing Body]. The Board authorizes the Community CEO and Leadership to establish, implement, and maintain ongoing Quality/Performance Improvement.

1. Observation on 02/18/19 at 11:53 AM revealed a patient presented to the ED in a wheelchair via ambulance with "psychiatric symptoms." Observation revealed staff transported the patient to the Evaluation Room, Room 17.

Observation of the evaluation room on 02/11/19 at 11:45 AM revealed an unsampled patient with his/her eyes closed lying on two (2) hard plastic/vinyl chairs that had been pushed together to form a sleeping surface. The room was observed to be furnished with six (6) hard rubber/vinyl chairs. The patient's head was resting on two pillows and his/her legs were hanging off the chair.

Further observation of the Evaluation Room on 02/14/19 at 1:25 PM with the Maintenance Director revealed he measured the room to be 199 square feet.

Observation of Patient #3 on 02/11/19 at 5:00 PM revealed the patient was lying on a sheet on the floor, with a pillow under his/her head. There were two (2) other patients in the Evaluation Room of the opposite sex. Interview with the patient revealed staff did not offer the patient a lunch meal and he/she "hoped" staff would provide a meal that evening.

Review of the facility's ED log for 02/01/19 through 02/13/19 and a list of patients seen in the Evaluation Room provided by the facility revealed twelve (12) patients stayed in the ED Evaluation Room for approximately twenty-four (24) hours, even though the room was not furnished with beds.

Review of the medical record for Patients #1, #3, and #5 revealed the patients spent approximately twenty-four (24) hours in the Evaluation Room. In addition, review of Patient #2's medical record revealed the patient spent over two days in the room.

Interview with Patient #2 on 02/11/19 at 1:22 PM revealed he/she was in the Evaluation Room with twelve (12) to thirteen (13) other psychiatric patients on 02/04/19. Patient #2 stated the patients wanted to fight and the female patients were taking off their clothes and were naked. Patient #2 stated, "People were laying in the floor, sitting in the chairs, and there were people everywhere." Further interview with the patient revealed he/she did not receive a meal while in the Evaluation Room and "had to beg for food" and for something to drink. Patient #2 stated he/she only got one snack box during the two days he/she stayed in the Evaluation Room.

Interview with Emergency Medical Services (EMS) Staff Member #1 on 02/12/19 at 12:15 PM revealed when they arrived on 02/06/19 at approximately 3:30 PM to transfer Patient #1 back to the nursing facility, Patient #1 was still in the Evaluation Room, sitting on one of the "hard chairs" in the room. According to EMS Staff Member #1, when RN #14 and a security guard assisted the patient from the chair, the patient's gown was soaked with urine and there was urine on the floor under the patient. EMS Staff Member #1 stated, "The urine smell was unbelievable." She stated that RN #14 stated to the patient, "I wish you had let me change you before EMS got here." Then RN #14 told EMS that as far as she knew the patient "hasn't been changed since you all dropped [him/her] off on 02/05/19."

Interview with the Administrator of the nursing facility (NF) on 02/12/19 at 10:15 AM revealed when Patient #1 arrived from the ED on 02/06/19, the patient was wearing three incontinence briefs that were soaked with urine. The patient's clothing was also soaked and urine was dripping from the patient's clothing. In addition, the NF Administrator stated the patient told her that he/she "had not ate anything" since the patient left the nursing facility. The NF Administrator stated she obtained a meal for the patient and the patient ate "like someone who was very hungry." The NF Administrator stated she reported her concerns with the patient's care to the facility House Supervisor on 02/06/19.

Review of a facility investigation dated 02/11/19, revealed the DON spoke with the nurses who cared for Patient #1, who stated the patient refused care/changed his/her own incontinence brief; however, there was no documented evidence that any further action was taken.

2. Review of the facility's policy, "Standard and Transmission Precautions," dated March 2018, revealed all healthcare workers would comply with infection prevention and procedures guidelines. The policy stated infection control precautions would be implemented to reduce the risk and transmission of infection by direct or indirect contact. Further review of the policy revealed staff would document the reason for instituting infection control precautions for each patient and place the appropriate signage on the patient's room door.

In addition, the "Standard and Transmission Precautions" policy stated staff would explain to the patient and their visitors the reason for the patient being placed on contact precautions and how it would affect them. In addition, staff would provide an educational handout to the patient/visitor and document the education. Continued review of the policy revealed gloves and a gown were required to be worn when entering a patient's room when contact precautions were warranted, and the gloves and gown would be removed prior to exiting the patient's room. Furthermore, staff would perform hand hygiene upon exiting the patient's room with soap and water or an alcohol-based hand rub.

Review of Patient #4's medical record revealed the facility admitted the patient on 11/21/18, and on 01/17/19 the patient was diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA) in the blood and sputum. Subsequently, Patient #4 was transferred to a private room. However, interviews with facility staff, Patient #4's Guardian, and visitors of Patient #4 revealed the facility failed to implement appropriate infection control procedures and failed to provide education to family and visitors regarding utilizing infection control precautions when visiting Patient #4. Further review of Patient #4's medical record revealed the patient was discharged to a skilled nursing facility on 02/08/19, but was readmitted less than twenty-four hours later on 02/09/19, with diagnoses including Healthcare-Associated Pneumonia, which the facility was treating with Vancomycin (an antibiotic used to treat drug-resistant bacteria). However, the facility failed to implement appropriate infection control measures for Patient #4, including alerting staff and visitors of the need to utilize infection control precautions. Observations of Patient #4 on 02/11/19 at approximately 11:40 AM revealed the patient was receiving IV Vancomycin and Zosyn (a Penicillin antibiotic used to treat resistant infections); however, further observation revealed there was no signage outside the patient's door or anywhere adjacent to the patient's room indicating the patient was on infection control precautions as required by the facility policy.

Review of Patient #6's medical record revealed the facility admitted the patient on 02/05/19, with diagnoses including End Stage Renal Disease, Acute Dehydration, and Diabetes. Observation of Patient #6 on 02/12/19 at 11:10 AM, revealed contact precaution signage was hanging outside of the patient's door; however, Registered Nurse (RN) #1 was in the patient's room and was not wearing gloves or a gown, the required Protective Personal Equipment (PPE) to be worn when a patient was on contact precautions. Further observations revealed RN #1 exited Patient #6's room without washing his hands or utilizing the antimicrobial hand sanitizer, which was located outside of Patient #6's room.

In addition, medical record review revealed seven (7) unsampled patients who were required to be on contact precautions per the facility's policies and procedures were observed on 02/12/19, without the precautions in place. Furthermore, observations and facility documentation revealed thirty-three (33) contracted nurses staffed the Three West Unit of the facility. However, interviews with staff and review of employee files revealed the contracted nurses were not consistently receiving appropriate continuing education and training related to the specifics of the facility's infection control program.

Interview with the Chief Executive Officer (CEO) on 02/20/19 at 4:44 PM revealed he was not a member of the Governing Body, but was appointed as the CEO by the Governing Body. He stated that the Governing Body met every other month and attended the meeting when they had face-to-face meetings that included the quality committee, infection control, general education sessions, and patient satisfaction. He stated that prior to the State Survey Agency's investigation initiated on 02/11/19, he was not aware patients were spending twenty-four (24) hours in the Emergency Department Evaluation Room or that more than six patients were in the room at one time. Further interview revealed the CEO was not aware that patients were not placed under contact precautions for infections that required precautions. He stated contact precautions were discussed during Governing Body meetings; however, no concerns had been identified. Further interview revealed that hospital acquired infections would have been discussed during Quality Assurance (QA) meetings; however, if the need to place a patient in isolation was not identified, the patient would not have necessarily been discussed during QA meetings. Continued interview with the CEO revealed he was made aware of patient complaints; however, he was only made aware if the Community Chief Regulatory Affairs Officer (CCRAO) could not resolve the concern at the "floor level."

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to protect and promote the rights of five (5) of ten (10) sampled patients. The facility failed to implement their grievance policy and failed to ensure a prompt resolution of the grievance for Patient #4. Patient #4's Guardian voiced a grievance regarding the patient's care. Although the Community Chief Regulatory Affairs Officer (CCRAO) acknowledged that Patient #4's Guardian voiced complaints, the facility failed to implement their grievance policy, failed to appropriately investigate the concerns, failed to document the patient representative's concerns, and failed to provide the representative with a resolution to the grievances (refer to A0118). In addition, the facility failed to ensure Patient #4's representative (as allowed under State law) was afforded the right to make informed decisions regarding the patient's care. On 01/22/19, the facility diagnosed Patient #4 with an Abdominal Aortic Aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen). However, due to the facility's failure to recognize that Patient #4's daughter had been appointed Guardian on 11/19/18, the patient's treatment of the emergent condition was delayed for approximately fourteen (14) days (refer to A0131).

Observations and interviews conducted during the investigation revealed upon arrival to the Emergency Department (ED) patients who presented with behavioral issues or were referred for a psychiatric evaluation were not placed in an ED bed, but were taken to the "Evaluation Room." However, the facility had no system in place to assure the privacy and safety of the patients while they were in the Evaluation Room. Observation of the Evaluation Room revealed the room was approximately 199 square feet and was furnished with six (6) chairs. Further observation revealed the room was not designed for the separation of male and female patients; regular chairs were taken into the room by staff, which have been thrown by patients; the toilet in the Evaluation Room did not have readily available water for hand washing; patients were locked inside the Evaluation Room, and the door will not open from the inside; patients have been observed to get into physical altercations with each other and attack staff in the room; and medical assessments, injections, and psychiatric evaluations are performed in the room in front of other patients who happen to be present at the time (refer to A0142).

In addition, record review revealed Patients #1, #3, and #5 spent approximately twenty-four (24) hours in the Evaluation Room and Patient #2 spent over two days in the room. Observation and interviews revealed the facility failed to provide the patients a place to sleep and patients had to sleep on the floor or on chairs. In addition, the facility failed to ensure Patients #1, #2, #3, and #5 received food and/or physician-ordered medications while they were patients in the room. Further, the facility failed to provide incontinence care for Patient #1, an immobile, incontinent, and confused patient who presented from a nursing facility and was in the Evaluation Room for approximately twenty-four (24) hours. Interview with a Nursing Facility Administrator revealed when the patient was transferred back to the nursing facility, the patient was wearing three (3) incontinence briefs that were soaked with urine, and urine was dripping from the patient. In addition, the patient stated he/she had not eaten since he/she left the nursing facility. Interview with Patient #2 revealed he/she had to "beg" for food and something to drink. Observation on 02/11/19 revealed Patient #3 was sleeping on a sheet on the floor and stated he/she "hoped" staff offered the patient a meal that evening (refer to A0145).

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to implement their grievance policy and failed to ensure a prompt resolution of the grievance for one (1) of ten (10) sampled patients (Patient #4). Patient #4 initially presented to the facility's Emergency Department on 11/21/18, for a psychiatric evaluation after displaying behaviors at home that threatened the patient's safety and the safety of others. However, during medical evaluation in the Emergency Department, it was determined that Patient #4 had a low heart rate, and the patient was admitted to the facility's medical floor. On 12/22/18, the facility diagnosed Patient #4 with an Abdominal Aorta Aneurysm (AAA). However, Patient #4 refused treatment for the condition and the facility failed to notify the patient's Guardian of the newly diagnosed condition. Therefore, Patient #4's treatment for the emergent condition was delayed approximately fourteen (14) days, until the facility realized that Patient #4's daughter was the Guardian and was to make medical decisions for the patient. On 01/06/19, Patient #4 underwent surgery for repair of the AAA. However, the patient's Guardian who was present in the facility's surgical waiting room, was not updated on the status of the patient during the surgical procedure, and stated when she was advised that the surgery was completed, the staff who notified her acted in an unprofessional manner. On 01/17/19, the facility diagnosed Patient #4 with Methicillin Resistant Staphylococcus Aureus (MRSA); however, the facility failed to notify the patient's Guardian of the diagnosis and failed to initiate appropriate infection control precautions. Furthermore, the Guardian was not notified when Patient #4 was moved to another room in the facility on 01/19/19. Although the Community Chief Regulatory Affairs Officer (CCRAO) acknowledged that Patient #4's Guardian made complaints about all the above issues, the facility failed to implement their grievance policy, failed to appropriately investigate the concerns, failed to document the patient representative's concerns, and failed to provide the representative with a resolution to the grievances.

The findings include:

Review of the facility's "Patient Grievance Policy," revised May 2012, revealed a complaint was a written or verbal communication made by a patient or a patient's representative regarding patient care services that could be effectively addressed and resolved by informal means. The policy also stated that a grievance was a written or verbal complaint that could not be resolved at the time the complaint was made, regarding the patient's care, abuse/neglect, privacy, or issues related to the organization's compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Continued review of the policy revealed any staff member could accept a patient complaint whether expressed verbally or in writing. In addition, the policy stated a complaint or grievance would be documented on a Patient/Customer Grievance/Concern form. The policy stated a complaint would be considered resolved when the patient/patient representative was satisfied with the actions taken on their behalf. The policy also stated that to resolve a grievance, the organization must provide the patient/patient representative with written notice of its decision and must include the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion.

1. Review of Patient #4's medical record revealed the facility admitted the patient on 11/21/18, with diagnoses of Schizophrenia, Bradycardia, Hypothyroidism, and Decreased Level of Consciousness. Interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM revealed she stated she arrived at the facility while the patient was still in the Emergency Department on 11/21/18. The Guardian stated she informed staff in the Emergency Department that she was Patient #4's Guardian and provided the facility all of her contact information.

Further review of Patient #4's medical record revealed the facility diagnosed the patient with an Abdominal Aortic Aneurysm (AAA) on 12/22/18; however, the facility failed to notify the Guardian of the new diagnosis because they failed to recognize that the daughter was the legal guardian of Patient #4. Although Patient #4's medical record detailed several attempts by the facility to educate Patient #4 of the dangers of not treating the AAA, the patient continued to refuse treatment and the patient's treatment was delayed approximately fourteen (14) days until the facility finally recognized that Patient #4's daughter was the patient's legal guardian who made medical decisions for the patient.

Interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM revealed she was not made aware of the patient's diagnosis of an AAA until 01/04/19. She stated she had visited the patient often during admission to the facility, but at no time did any staff bring this to her attention. She stated she had informed the facility on 11/21/18 when the resident was admitted that she was the legal guardian and provided the facility with her phone number.

Review of a Multidisciplinary Progress Note dated 01/04/19 at 4:30 PM revealed RN #11 documented that Patient #4's Guardian had been to the facility to visit the patient and (the Guardian) was visibly upset and crying at the patient's bedside. The documentation stated that the Guardian had just found out the patient had been diagnosed with an AAA on 12/22/18, and no one had informed her. The Documentation stated the patient's Guardian had voiced that she had been to the facility multiple times visiting the patient, but no one had informed her of the diagnosis. Continued review of the documentation revealed RN #11 verbalized concerns of poor communication between providers and departments. The documentation stated that the patient's daughter had Guardianship papers at home and that she was the patient's legal guardian. The Guardian also requested that Patient #4's physician contact her at home. RN #11 also documented that she verified that the phone number on Patient #4's medical record was the correct phone number listed for the Guardian. Review of a Multidisciplinary Progress Note dated 01/05/19 at 2:00 PM revealed Physician #8 was on the phone discussing Patient #4 with the Guardian. A subsequent Multidisciplinary Progress Note dated 01/05/19 at 2:30 PM revealed Patient #4's Guardian called and stated she would be at the facility on 02/06/19 and would bring Guardianship papers for Patient #4 and would sign consent for the patient's surgical procedure.

Further interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed she called the CCRAO on 01/11/19 and voiced concerns that she was never notified of Patient #4's AAA, and stated "[the patient] could have died because you all didn't call me." The Guardian stated the CCRAO told her she would look into the complaint and get back in touch with her. However, according to the Guardian she has never been contacted about the complaint and never received any type of resolution.

2. Review of Patient #4's medical record and interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed Patient #4 had surgery on 01/09/19 to repair an Abdominal Aortic Aneurysm. The Guardian stated she was present at the facility during the surgery, but was not kept updated about the patient's condition during the surgery. The Guardian stated she was not told anything until after the surgery had been completed and a "well-dressed man" came out into the waiting room and asked for the patient's family. The Guardian stated when she spoke up indicating she was the family, she stated the man "threw his hands up" and said "act surprised." The Guardian stated she asked the man if the patient was doing okay and he said yes, made a clicking sound, and then proceeded to give a "thumbs up" sign.

Further interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed she called the CCRAO on 01/11/19 and voiced a complaint about the man that came out and talked to her after Patient #4's surgery. She stated that the CCRAO told her she would look into the complaint and get back in touch with her. However, according to the Guardian she has never been contacted about the complaint and never received any type of resolution.

3. On 01/19/19, the facility diagnosed Patient #4 with a MRSA infection, and moved the patient to a private room on the Telemetry Unit. However, interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed the facility failed to notify her of the resident's new diagnosis or that the patient had been moved to another room on another unit. The Guardian stated she arrived at the facility to visit Patient #4 on 01/19/19, and discovered the patient had been moved. The Guardian stated when she found Patient #4 on the Telemetry Unit approximately an hour and a half after the patient had been moved, she was told by the nurse that the patient had been moved because of a diagnosis of MRSA. However, the Guardian stated there was no signage posted to indicate the patient had been placed on contact precautions and she had been provided no education related to what infection control precautions she should take when visiting Patient #4.

Continued interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed she called and spoke with the CCRAO again on 01/20/19 after Patient #4 had been transferred from the Critical Care Unit to the Telemetry Unit on 01/19/19 due to the diagnosis of MRSA. She stated she made a complaint that she was not informed of the patient's transfer on 01/19/19 and did not find out about the move until she arrived at the facility to visit the patient. The Guardian stated that the nurse caring for Patient #4 on 01/19/19 did not educate her on precautions to take when visiting with the patient and that there was no signage outside of the patient's room indicating that the patient was on contact precautions. The Guardian also reported to the CCRAO that staff did not wear a gown or gloves when they entered the patient's room to provide care. However, further interview with the Guardian revealed she did not receive any correspondence from the CCRAO about any of the complaints that she had voiced.

Interviews were conducted with the CCRAO on 02/12/19 at 12:15 PM, 02/14/19 at 4:31 PM, and 02/20/19 at 6:30 PM. The CCRAO stated that she had spoken to Patient #4's Guardian a couple of times related to concerns the Guardian had regarding care and services the facility had provided to Patient #4. The CCRAO acknowledged that the Guardian had voiced complaints including not being notified when the patient was diagnosed with an AAA, the treatment the family received in the waiting room after Patient #4's surgery, that she was not notified when Patient #4 was moved to another room on 01/19/19, and that infection control precautions were not being implemented by staff. However, the CCRAO could not state the date or time she had spoken with the Guardian because she did not document the date, time, or contents of the conversations, because she did not feel that filing a grievance was warranted. The CCRAO stated that if the patient was still admitted to the facility when a complaint was made, the facility did not consider that a grievance because they could try to resolve the complaint while the patient was still in the facility. The CCRAO stated that if the patient had been discharged when the complaint was received a grievance would have been filed and an investigation would have been completed.

Continued interviews with the CCRAO on 02/12/19 at 12:15 PM, 02/14/19 at 4:31 PM, and 02/20/19 at 6:30 PM, revealed that after speaking with Patient #4's Guardian she had asked the unit managers assigned to the applicable areas to review the patient's chart, and to then call the patient's Guardian and answer her questions. However, the CCRAO stated she conducted no follow-up with the unit managers to ensure they contacted the patient's Guardian, and "assumed" the Guardian's complaints were resolved. Further interview with the CCRAO revealed that if the nurse managers did not get in contact with the Guardian, or the Guardian was still upset after talking to the unit managers, the facility would then "consider it a grievance" and an investigation would have been completed.

Interview with Nurse Manager #1 on 02/14/19 at 5:33 PM revealed she was contacted by the CCRAO (exact date and time unknown) related to Patient #4's Guardian being upset because she had not been made aware of the patient's transfer on 01/19/19. She stated she went to the patient's room and spoke with whomever was in the room with the patient and apologized. However, the unit manager stated she was not sure if the visitor was the patient's Guardian. Continued interview revealed the unit manager stated she spoke with staff about informing family members/guardians when a patient's room was changed.

Interview with Nurse Manager #2 on 02/14/19 at 5:10 PM revealed she was never told of any complaints made by Patient #4's Guardian. She stated the patient's Guardian told staff on her unit about the incident in the surgery waiting room on 01/09/19 and staff had told her about it, but she did not do anything with the information she was given.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) Health Statistics, it was determined the facility failed to ensure the patient's representative (as allowed under State law) was afforded the right to make informed decisions regarding the patient's care for one (1) of ten (10) sampled patients (Patient #4). On 01/22/19, the facility diagnosed Patient #4 with an Abdominal Aortic Aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen). However, due to the facility's failure to recognize that Patient #4's daughter had been appointed Guardian on 11/19/18, the patient's treatment of the emergent condition was delayed for approximately fourteen (14) days.

The findings include:

Interview with the Community Chief Regulatory Affairs Officer (CCRAO) on 02/14/19 at 4:31 PM and the Director of Quality Improvement (DQI) on 02/18/19 at 7:13 PM revealed the facility did not have a policy to ensure the notification of a patient's guardian when a patient was diagnosed with a condition that required surgical intervention.

Data published by the CDC's National Center for Health Statistics demonstrated that aortic aneurysm dissection (rupturing of the aorta) was among the fifteen (15) leading causes of death for people aged 60-84 years old in the United States.

Review of Patient #4's medical record revealed the patient was admitted to the facility on 11/21/18 with diagnoses of Schizophrenia, Bradycardia, Hypothyroidism, and Decreased Level of Consciousness. Continued review of the patient's medical record revealed an "Order for Emergency Appointment of Fiduciary" dated and signed by the judge on 11/19/18, which appointed Patient #4's daughter as the patient's temporary guardian. However, review of Patient #4's admission consents and Advanced Directives dated 11/21/18 revealed no signatures were obtained due to the patient "having an altered mental status."

Further review of the medical record revealed Patient #4 was diagnosed with an Abdominal Aortic Aneurysm (AAA) on 12/22/18 when the facility performed a CT (computerized tomography) scan of the patient's lumbar spine due to weakness. However, there was no evidence found to indicate that the facility contacted the patient's guardian to notify them of the emergent diagnosis.

Review of a Multidisciplinary Progress Note dated 12/22/18 at 6:01 PM documented by Advanced Practice Registered Nurse (APRN) #1 revealed she discussed the new diagnosis with Patient #4 and the need for the patient to have a CT Angiogram of the area and the need to transfer the patient to another facility. However, according to the documentation, Patient #4 refused both the procedure and transfer. Continued review of the note revealed the APRN spent fifteen (15) minutes with the patient, educating him/her on aneurysms and the danger associated with them, but Patient #4 continued to refuse the CT scan and transfer stating, "If that thing busts in there I'll just die," and further stated, "I just want to go home." However, there was still no evidence found to indicate that Patient #4's Guardian was notified of the patient's condition.

Review of a Psychiatric Evaluation dated 11/23/18 at 9:00 AM conducted by the facility for Patient #4 revealed the facility documented that the patient's daughter was "looking at guardianship"; however, the facility failed to contact the daughter regarding the patient's critical condition and failed to recognize that the daughter had already been appointed as the patient's Guardian on 11/19/18. Further review revealed the psychiatric evaluation documented an impression of "Major Neurocognitive Disorder."

Further review of Patient #4's medical record revealed that due to the patient's continued refusal to obtain treatment for the AAA, the facility ordered a psychiatric consultation for Patient #4. Review of the Psychiatric Consult dated 12/30/18 at 1:00 PM, revealed the patient had a "lack of capability for decision making at this time and a substitute decision maker was recommended related to AAA repair." Subsequently, review of a Social Services Note dated 12/31/18 at 1:40 PM revealed the facility made a request for a Guardianship referral; however, the referral could not be conducted until 01/02/19 due to the holidays.

Review of a Social Services Note dated 01/02/19 at 2:15 PM revealed the Social Worker made a referral for State Guardianship. Furthermore, the note revealed the Social Worker spoke with Patient #4's daughter and learned that the daughter had already been appointed as Patient #4's Guardian on 11/19/18.

Review of a Multidisciplinary Progress Note dated 01/05/19 at 2:00 PM revealed Physician #8 was on the phone with Patient #4's Guardian, who was agreeable to the surgical procedure for treatment of Patient #4's AAA.

Review of a Patient Assessment Flow Sheet dated 01/06/19 at 4:00 PM revealed Patient #4's Guardian signed consent for the patient to undergo surgical repair of an AAA and the procedure was performed on 01/06/19, approximately 14 days after Patient #4 received the emergent diagnosis.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure patient privacy and safety requirements were met when patients were placed in the facility's Evaluation Room. Observations and interviews conducted during the investigation revealed upon arrival to the Emergency Department (ED), patients who presented with behavioral issues or were referrals for psychiatric evaluation were not placed in an ED bed, but were taken to the "Evaluation Room." However, the facility had no system in place to assure the privacy and safety of the patients while they were in the Evaluation Room. Observation of the Evaluation Room revealed the room was not designed for the separation of patients, the toilet in the Evaluation Room did not have readily available water for hand washing, and the door of the Evaluation Room was locked and would not open from the inside. Interviews with patients and staff revealed patients had to lie on the floor due to not having beds or enough chairs in the room, residents had thrown chairs, and patients had been observed to get into physical altercations with each other and attack staff in the room. In addition, interviews with staff revealed medical assessments, injections, and psychiatric evaluations were conducted in the room in front of any patients who happened to be present at the time.

The findings include:

Interview with the Emergency Department (ED) Director on 02/13/19 at 3:15 PM revealed the facility had no specific policies or procedures in place which govern the safety and privacy of patients while in the Evaluation Room. However, review of the facility's policy titled, "Patients' Rights and Responsibilities," dated 04/27/19 revealed patients would receive considerate, respectful, and compassionate care with dignity and comfort. Further review of the facility's policy revealed patients should expect reasonable safety in as far as the hospital practices and environment is concerned.

Observation of the Evaluation Room on 02/11/19 at 11:45 AM revealed one patient was present in the room and was lying on two straight-backed hard rubber/vinyl chairs, which had been pushed together so the patient could lie down. The patient's eyes were closed and the patient's head was resting on two pillows and the patient's legs were hanging off the chair from the calf down. Further observations on 02/11/19 at 5:00 PM revealed three patients were present in the Evaluation Room and Patient #3 was observed to be lying on the floor with a pillow under his/her head.

Observation and measurement of the Evaluation Room on 02/14/19 at 1:25 PM with the Maintenance Director revealed the room had approximately 199 square feet of area space. Further observation of the Evaluation Room revealed six (6) hard rubber/vinyl straight back weighted chairs were in the room. The room also had one (1) mirrored glass "window," which was adjacent to a room where the nurse was located. The mirrored window allowed the nurse to see into the room, but occupants in the Evaluation Room could not see through the window. The Evaluation Room also had one connecting restroom for both male and female patients to utilize. Observation of the restroom located in the Evaluation Room on 02/14/19 at 6:15 PM revealed a toilet bowl with a sink attached above it. However, there were no handles on the sink to turn the water on or off. There was a button located on the right lower side of the toilet to turn the water in the sink on; however when the staff member pushed the button, the water would not come on. The staff member then pushed another button located on the left lower side of the toilet; however, again the water did not come on. Eventually, staff located another button on the left lower side of the toilet and when it was pushed by the staff the water in the sink came on. Further observation revealed that although the Evaluation Room door could be opened from the outside by staff, it immediately locked when the door was shut, and could not be opened from inside the Evaluation Room.

Review of Patient #1's medical record revealed the patient was transferred to the facility by Emergency Medical Services (EMS) on 02/05/19 at 4:40 PM from a nursing facility due to an involuntary petition for a behavioral health evaluation. Further review of the medical record revealed that upon arrival the facility placed Patient #1 in the Evaluation Room. Review of Patient #1's medical record revealed the facility assessed the patient to be disoriented to person, time, place, and situation; to utilize incontinence briefs; to be at high risk for falls; and was unable to comprehend education. However, interviews with staff and review of the patient's medical record revealed no evidence the patient was provided incontinence care, had interventions implemented to ensure the patient remained free from falls or skin breakdown, or had interventions implemented to ensure the patient's emotional safety due to being in an unfamiliar environment with cognitive deficits.

Review of an EMS run sheet dated 02/06/19 at 1:30 PM and interview with Emergency Medical Technician (EMT) #1 on 02/12/19 at 12:15 PM, revealed when Resident #1 was transported to the facility on 02/05/19, the patient was clean, dry, and free from body odor. However, EMT #1 stated that upon arrival to the facility on 02/06/19 at 3:00 PM, to transport the patient back to the nursing facility Patient #1 was still in the Evaluation Room, in a wheelchair, and there was a large puddle of urine dripping from Patient #1 and pooling in the floor and running out from under the chair. The EMT stated, "When we opened the Evaluation Room door, the smell of urine would knock you down." The EMT stated that a patient of the opposite sex was also in the Evaluation Room with Patient #1, and no privacy or supervision was being provided for the patients.

Review of Patient #2's medical record and interview with the patient on 02/11/19 at 1:22 PM, revealed the patient arrived at the facility on 02/02/19 at 8:26 PM. Patient #2 stated upon arrival to the ED he/she was placed in the Evaluation Room and remained there for three nights. Furthermore, Patient #1 stated that as many as twelve (12) or thirteen (13) other patients were also in the room at times.

Further review of Patient #2's medical record revealed on 02/02/19 at 10:35 PM, a physician completed a mental health evaluation for Patient #2 in the Evaluation Room. However, there was no evidence in the patient's medical record to indicate any privacy was afforded Patient #2 during the examination, and no provisions were made to ensure HIPAA requirements were maintained. In addition, review of the examination assessment performed stated that Resident #2 had suicidal ideations, vague homicidal thoughts, auditory and visual hallucinations, exhibited paranoia, and believed people were out to get him/her. However, there was no evidence in the patient's medical record to indicate any safety precautions were implemented to ensure the safety of other patients in the room should Patient #2 act upon the "vague homicidal thoughts."

Review of the facility's ED log and a list of patients who were evaluated/treated in the Evaluation Room revealed on 02/03/19 through 02/04/19 approximately seven (7) patients were present in the room at one time and approximately four (4) patients (male and female) spent the night in the room, which included Patient #2. Continued review of the documentation for 02/04/19 through 02/05/19 revealed approximately fourteen (14) patients were present in the room at one time, and approximately ten (10) patients (male and female) spent the night in the Evaluation Room, which included Patient #2.

Further interview with Patient #2 on 02/11/19 at 1:22 PM, revealed during the time the patient was in the Evaluation Room "all the patients wanted to fight and the women were taking off their clothes and were naked." Patient #2 stated, "People were laying in the floor, sitting in the chairs, and there were people everywhere." Patient #2 stated that there was no privacy available in the room, and the door was locked, and the patient stated it was "scary." Continued review of Patient #2's medical record revealed the patient remained locked in the Evaluation Room with other patients, was provided only one meal, and had to sleep on the floor until 02/05/19 at 1:11 AM (approximately three days), when the patient was transferred to the psychiatric unit.

Interview with Security Guard (SG) #1 on 02/13/19 at 6:03 PM revealed he had seen eight (8) to nine (9) patients waiting in the Evaluation Room at one time. SG #1 stated approximately one (1) to two (2) weeks ago twelve (12) or thirteen (13) patients had been in the Evaluation Room at the same time. The SG stated patients have to lie and sit on the floor, which he said was "unsanitary" and created a fall risk for other patients. The SG stated there was no way to provide privacy for any of the patients. Further interview revealed patients in the room often take their clothes off and will not put them back on. The SG stated, "Sometimes people stay in the room for three days."

Interview with SG #2 on 02/14/19 at 2:55 PM revealed during the week of 01/30/19 to 02/05/19 there were thirteen (13) to fourteen (14) patients one night in the Evaluation Room. SG #2 stated patients have to sleep on the floor, and he had witnessed several fights break out in the room. The SG stated the patients will take off their clothes and if they refuse to put them back on, "they stay naked in the room." The SG stated that there was no way to provide privacy in the room and if patients did not want to see another person naked, "they would have to close their eyes." SG #2 also stated there were no provisions for basic hygiene or infection control in the room, and stated the naked patients sit and lie wherever they want to and then other patients have to sit and lie in the same places.

Interview with RN #3 on 02/14/19 at 3:20 PM, revealed on 02/04/19 there were at least thirteen (13) patients in the Evaluation Room at the same time. He further revealed that the patients had to sit on the floor because there was no other choice. RN #3 stated one of the female patients took her clothes off three (3) times. The RN stated he dressed her each time; however, she refused to keep her gown on and stood in the corner of the Evaluation Room naked, while other female and male patients watched her. RN #3 stated there were no provisions made for separation of men and women and no privacy was available in the room.

Interview on 02/19/19 at 6:03 PM with RN #17 revealed he had been working in the Evaluation Room for two years. The RN stated on 02/11/19, there were nine (9) patients in the Evaluation Room at the same time. The RN stated patients that did not have chairs had to sit on the floor and some patients lay on the floor. The RN stated that during this time one patient who "was strung out on meth according to the cop that brought (him/her) in, was going ballistic in the room." RN #3 stated the patient was kicking the door, attempted to attack the guard, and hit him. RN #3 stated the physician ordered the patient to receive "an injection" which was administered to the patient in the Evaluation Room with the other eight patients present. RN #3 also stated at times they do bring "regular" unweighted chairs into the room for patients to sit in, but stated that created an unsafe environment. The RN stated the patients will throw the chairs and on one occasion, a patient threw a chair into the two-way mirrored window and stated, "It scared me to death." RN #3 also stated that when both male and female patients are present in the room, the men sometimes make sexual advances toward the females. He stated one time there was a "young female" in the room and a male patient tried to "sweet talk" her, so RN #3 stated he removed the female from the room and placed her in his office to "protect her."

Interview with the ED Nurse Manager on 02/11/19 at 5:20 PM and 02/13/19 at 3:15 PM, revealed the nurses in the Evaluation Room were responsible for the care and safety of patients in the Evaluation Room.

Interview with the Emergency Department (ED) Director on 02/13/19 at 3:15 PM revealed he was aware patients had to stay in the Evaluation Room for extended periods at times. The ED Director stated patients were kept in the Evaluation Room for "safety reasons." However, the ED Director was unable to state how the safety of the patients in the evaluation was ensured, other than stating a guard was stationed close to the area at all times. The ED Director also stated the Evaluation Room was furnished with heavy chairs that could not be picked up/thrown and there were no items in the room that the patients could use to harm themselves/others. However, the ED Director stated he had been unaware that regular chairs were at times brought into the room by staff. The ED Director stated the facility had no policy or procedure in place to separate male and female patients who were waiting to receive psychiatric services, or any policies or procedures in place to ensure the privacy of patients while in the Evaluation Room.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to protect four (4) of ten (10) sampled patients from neglect. Observation and interview revealed when patients presented to the Emergency Department (ED) with behavioral health concerns, the patients were taken to "the Evaluation Room" where they stayed until they were discharged, transferred, or admitted to the facility. Observation revealed the Evaluation Room was furnished with six chairs in an approximately 199 square foot room. Record review revealed Patients #1, #3, and #5 spent approximately twenty-four (24) hours in the Evaluation Room and Patient #2 spent over two days in the room. Observation and interviews revealed the facility failed to provide the patients a place to sleep and patients had to sleep on the floor or in chairs. In addition, the facility failed to ensure the patients received food and physician-ordered medications while they were patients in the room. Further, the facility failed to provide incontinence care for Patient #1, an immobile, incontinent, and confused patient who presented from a nursing facility and was in the Evaluation Room for approximately twenty-four (24) hours.

The findings include:

Review of the facility's policy titled "Suspected Abuse/Neglect/Exploitation of Patients and Reporting," dated July 2017, revealed neglect is considered a form of abuse and is defined as the failure to provide goods or services necessary to avoid physical harm or mental anguish. Further review of the policy revealed there would be adequate, qualified, trained, and experienced staff to ensure the care needs of every patient were met.

Review of the facility's policy titled "Patient Care Flow Record," dated 10/01/05, revealed patient food intake should be documented. The policy stated the key to record the amount and method of consumption should be used to record intake at breakfast, lunch, afternoon snack, dinner, and evening snacks.

Review of the facility's policy titled "Medication Administration," dated 01/02/07, revealed medications should be ordered by a credentialed, licensed independent practitioner and should be administered by a healthcare professional registered to do so in the state where they were practicing. Further review of the policy revealed medication safety and administration was a joint effort between the Pharmacy Department and the Nursing Department.

Interview with the ED Director on 02/13/19 at 3:15 PM revealed patients who presented to the ED with "psychiatric" symptoms were taken to the Evaluation Room after triage, but at times were triaged in the Evaluation Room. The Director stated a nurse was assigned to care for patients in the room, and was stationed in an adjoining room. He stated the nurse assigned was a psychiatric nurse, but the Emergency Department was responsible for the patient's care.

Observation on 02/18/19 at 11:53 AM revealed an unsampled patient presented to the ED in a wheelchair, via ambulance, with "psychiatric symptoms." Observation revealed staff transported the patient directly to the Evaluation Room, Room 17.

Observation of the Evaluation Room on 02/11/19 at 11:45 AM revealed an unsampled patient with his/her eyes closed lying on two (2) hard rubber/vinyl chairs that had been pushed together to form a sleeping surface. The patient's head was resting on two pillows and his/her legs were hanging off the chair.

Further observation on 02/11/19 at 5:00 PM revealed Patient #3 lying on a sheet on the floor, with a pillow under his/her head. There were two (2) other male patients in the Evaluation Room. At 5:10 PM, Registered Nurse (RN) #14 came into the Evaluation Room and asked the patient to get off the floor.

Further observation of the Evaluation Room on 02/14/19 at 1:25 PM with the Maintenance Director revealed he measured the room to be approximately 199 square feet. Further observation of the Evaluation Room revealed six (6) hard rubber/vinyl chairs occupied the space.

1. Review of Patient #1's medical record revealed the patient presented to the ED via Emergency Medical Services (EMS) on 02/05/19 at 4:26 PM from a nursing facility due to an involuntary petition for a behavioral health evaluation. According to the Triage Assessment dated 02/05/19 at 5:02 PM, Patient #1 presented with diagnoses of "Schizophrenia, Bipolar Disorder, and Anxiety, and other mental illness." The assessment stated the patient was "Physically and verbally abusive toward staff and others, kicking, pinching, biting, pulling hair, and wrapped arms and legs around employee and tried to bite her." In addition, the form stated Patient #1 "threatens to kill others and cause them physical harm."

Review of Patient #1's Nursing Home to Hospital Transfer Form dated 02/05/19, completed by the nursing facility revealed the patient utilized a rolling walker, was at risk for falls, and was transferred to the facility due to behaviors. The Nursing Home Transfer Form revealed Patient #1's medications included Ativan three times a day (treats anxiety), Haldol four times per day (treats Schizophrenia), Paliperidone one time daily (treats Schizophrenia), Norco twice daily (treats Chronic Pain), Keppra (treats seizures), and Celexa once daily (treats depression). Further review revealed the patient required a pureed diet with large portions and a barrier cream after each incontinence episode. In addition, the Nursing Home Transfer Form revealed Patient #1 had redness to the right hip and required a pressure-reducing mattress.

Further review of Patient #1's Triage Assessment dated 02/05/19 at 4:26 PM revealed the patient was not oriented to person, place, time, or situation. When asked to state his/her name, the patient gave an incorrect name. The patient stated he/she did not know where he/she was or why he/she was there. The assessment stated the patient was confused and disoriented, but cooperative and followed directions.

Further review of Patient #1's ED Medical Record revealed the facility documented the medications that the patient routinely took at the nursing facility.

Review of Patient #1's Fall Risk Assessment dated 02/05/19 at 4:26 PM revealed the patient was weak with walking and transferring, and was on bed rest/nurse assistance for ambulation. Further review revealed the assessment determined the patient was at moderate risk for falls, and moderate fall risk precautions were implemented. However, the documentation revealed the patient was unable to comprehend education regarding fall risk precautions.

Review of the Edmonson Fall Risk assessment dated 02/05/19 at 4:40 PM revealed the patient was independent with control of bowel and bladder, even though the Nursing Home Transfer Form revealed the patient was incontinent. In addition, the assessment stated the patient was immobile, confused/disoriented, and took psychotropic medications. According to the assessment, Patient #1's Edmonson Fall Risk Score was 105, and a patient was a fall risk if the score was 90 or higher. Further review of the assessment revealed when the score was 90 or higher, fall precautions were required that included labeling the patient's door, and keeping the bed in the lowest position.

Review of Patient #1's "Psych Intake" notes dated 02/05/19 at 4:40 PM revealed the patient stated, "I suppose I need a bed here," when asked about his/her expectations of treatment. Further review revealed Patient #1 had moderately impaired comprehension and mildly impaired oral ability. According to the note, facility staff documented Patient #1 was independent with ambulation/steady gait, but was immobile.

Continued review of Patient #1's ED notes dated 02/05/19 at 10:00 PM revealed the Qualified Mental Health Professional (QMHP) evaluated the patient and the patient did not meet the criteria for an admission to the behavioral health unit. However, further review of Patient #1's ED notes revealed an ambulance was not available to transport the patient back to the nursing facility until "sometime" after 8:00 PM on 02/06/19. According to the ED record, Patient #1 was not discharged until 02/06/19 at 3:30 PM.

Further review of Patient #1's ED record revealed no documented evidence a meal/food was ordered or provided to the patient during the approximately twenty-four hours that the patient was in the ED Evaluation Room. In addition, there was no documentation that staff administered any medications to the patient or provided incontinence care. Further, there was no documentation that a bed was provided for Patient #1 during the approximately twenty-four hours that the patient was in the ED Evaluation Room, even though the medical record stated the patient was on bedrest, that the bed should be kept in the lowest position, and the nursing facility documentation revealed the patient required a pressure reduction mattress.

Review of an Ambulance Run Sheet dated 02/06/19 at 1:30 PM revealed upon EMS arrival Patient #1 was found in the "ED area psych eval [evaluation] room." "Room had only hard plastic furniture, no beds. There was also another male patient in the room and both were unsupervised. RN on duty stated that patient's brief [incontinence brief] had not been changed since [Patient #1] had been there."

Interview with Emergency Medical Service (EMS) Staff Member #1 on 02/12/19 at 12:15 PM revealed that when they transferred Patient #1 to the facility on 02/05/19 at approximately 3:00 PM, Patient #1 was clean and free from any odor. However, EMS Staff Member #1 stated when she and EMS Staff Member #2 arrived at the facility on 02/06/19 at approximately 3:30 PM to transfer Patient #1 back to the nursing facility, Patient #1 was still in the Evaluation Room, sitting on one of the "hard chairs" in the room. EMS Staff Member #1 stated, "When we opened the door (to the Evaluation Room) a strong smell of urine hit us." According to EMS Staff Member #1, when RN #14 and a security guard assisted the patient from the chair, the patient's gown was soaked with urine and there was urine on the floor under the patient. EMS Staff Member #1 stated, "The urine smell was unbelievable." She stated that RN #14 stated to the patient, "I wish you had let me change you before EMS got here." Then RN #14 told EMS staff that as far as she knew, the patient "hasn't been changed since you all dropped [him/her] off on 02/05/19."

Interview with RN #14 on 02/11/19 at 11:50 AM revealed she provided care for Patient #1 on 02/05/19 until 7:00 PM and on 02/06/19 from 7:00 AM until the patient was discharged at approximately 3:30 PM. RN #14 stated when Patient #1 presented to the ED, she placed a clean incontinence brief on the patient. Further interview with RN #14 on 02/13/19 at 1:30 PM revealed Patient #1 refused incontinence care during the rest of his/her stay in the Evaluation Room on 02/05/19 and 02/06/19. In addition, the interview revealed if the patient had allowed staff to provide incontinence care, the RN would have to assist the patient to a chair in the bathroom. Further interview with RN #14 revealed she thought she asked a security guard to bring Patient #1 a meal tray on the evening of 02/05/19, but the patient refused to eat. RN #1 revealed she was responsible for documenting when a patient ate or refused meals; however, she failed to document regarding Patient #1's food intake on 02/05/19 and 02/06/19.

Interview with RN #15 on 02/12/19 at 3:55 PM revealed he provided care for Patient #1 until 7:00 PM on 02/05/19. RN #15 stated he remembered offering Patient #1 something to drink, but could not remember if Patient #1 received a meal tray or if he/she was offered a snack box. According to RN #15, he did not provide incontinence care or change the patient's brief. He stated Patient #1 used the restroom independently. Even though review of the patient's record revealed the patient was immobile, had no assistive device (walker, wheelchair) for walking, and was incontinent, RN #15 stated he observed the patient walk to the restroom and he obtained a urine specimen.

Interview with the Dietary Manager on 02/11/19 at 4:37 PM confirmed Patient #1 did not receive a meal while a patient at the facility. The Dietary Manager stated she had never sent a pureed meal to the Evaluation Room.

Interview with the Administrator of the nursing facility (NF) on 02/12/19 at 10:15 AM revealed when Patient #1 arrived from the ED on 02/06/19, the patient was wearing three incontinence briefs that were soaked with urine. The patient's clothing was also soaked and urine was dripping from the patient's clothing. In addition, the NF Administrator stated the patient told her that he/she "had not ate anything" since the patient left the nursing facility. The Administrator stated she obtained a meal for the patient and the patient ate "like someone who was very hungry." The NF Administrator stated Patient #1's bottom was also red when the patient arrived back at the nursing facility. The NF Administrator stated she reported her concerns with the patient's care to the House Supervisor on 02/06/19.

Review of the facility's investigation revealed on 02/06/19 at 3:30 PM the Nursing Facility Administrator contacted House Supervisor #2 stating that Patient #1 had been transported back to the nursing facility with "three briefs on, odorous, briefs very weighted as if not changed." House Supervisor #2 notified the Director of Nursing and the Executive Director of the report. Further review of the investigation revealed on 02/11/19 at 2:32 PM, five days later, the DON stated she spoke with the RN [RN #14] who was working in the Evaluation Room the day the patient arrived; the RN stated the patient "would not allow for staff to help [him/her] change his/her brief when it got wet. States the patient took the clean brief and placed over top the old brief." The nurse also stated she made several attempts to change the patient, but the patient refused every time. In addition, the investigation revealed the DON also spoke with the RN who worked the Evaluation Room the night the patient came in (RN #15) and the RN stated the "patient was given a brief during the night and did change [his/her] brief without any problems."

Interview with House Supervisor #2 on 02/13/19 at 3:20 PM revealed she denied that the Nursing Facility Administrator reported that Patient #1 did not receive food or medications.

Interview with the Director of Nursing (DON) on 02/12/19 at 2:50 PM, revealed the facility did not identify that staff were not clear on the care the patient required and took no further action regarding the allegation that Patient #1 did not receive incontinence care while a patient at the facility. In addition, the DON stated she was not aware there was a report that the patient was not fed. Further, the interview revealed that no one identified that Patient #1, who was immobile, incontinent, and required a bed with a pressure reduction mattress stayed in a chair for approximately twenty-four (24) hours.

Interview with the Medical Director on 02/18/19 at 5:20 PM revealed that Patient #1's medications should have been ordered and administered because the patient was in the Evaluation Room for so long. The physician stated the patient especially needed the Ativan and Keppra medications.

2. Interview with Patient #2 on 02/11/19 at 1:22 PM revealed he/she was in the Evaluation Room with twelve (12) to thirteen (13) other psychiatric patients on 02/04/19. Patient #2 stated the patients wanted to fight and the female patients were taking off their clothes and were naked. Patient #2 stated, "People were laying in the floor, sitting in the chairs, and there were people everywhere."

Review of Patient #2's ED medical record revealed the patient presented to the ED on 02/02/19 at 8:26 PM with "Psychiatric Symptoms." Review of the Triage Assessment dated 8:27 PM revealed the patient arrived via Law Enforcement and was "here on a uniform citation. Per citation, patient told officer that when [the patient] got home [the patient] wanted to kill [him/her] self and also walked in traffic this evening. Patient states that [he/she] went home and someone started picking on [him/her] and calling [him/her] a rat and [he/she] didn't want to stay there so [he/she] told the officer [he/she] wanted to kill self."

Review of Patient #2's "Psych Intake" dated 02/04/19 at 8:32 PM revealed the patient was fully alert and oriented at all times with concrete thought processes, intact memory, and "appropriate" behavior. The intake revealed the patient had no indication of aggressive behavior; no significant anger, hostility, or irritability in mood; no indication of self-harm, and no delusions/hallucinations. Further review revealed the patient was at moderate risk for suicide and required observation and documentation every seven and one-half minutes.

Further review of Patient #2's medical record revealed on 02/02/19 at 10:35 PM, a physician completed a mental health evaluation for Patient #2. The evaluation stated he saw and examined the patient in the psychiatric area room [Evaluation Room] for suicidal ideation and vague homicidal thoughts. The patient also had auditory and visual hallucinations, exhibited paranoia that his/her neighbors were out to get him/her, and used methamphetamine. According to the note, the QMHP had also evaluated the patient and the recommendation was to place the patient under a 72-hour hold because the patient "did not have the mental capacity to be able to voluntarily commit [him/her] self."

Review of Patient #2's Physician orders dated 02/03/19 at 3:26 AM revealed an order to admit the patient. However, interview with the Executive Director of the Psychiatric Unit on 02/11/19 at 12:40 PM revealed from 01/30/19 until 02/05/19 the Psychiatric Unit was at full capacity. He stated the unit had flooded and twenty-five beds were not available. He stated when a patient was discharged and a bed became available, a patient was transferred from the Evaluation Room to the Psychiatric Unit.

Further review of Patient #2's physician orders dated 02/03/19 at 3:26 AM, revealed a regular diet was ordered for the patient. According to the patient's medical record, nursing staff ordered a regular diet for the patient while in the Evaluation Room. However, continued interview with Patient #2 on 02/11/19 at 1:22 PM revealed he/she did not receive a meal while in the Evaluation Room and "had to beg for food" and for something to drink. Patient #2 stated he/she only got one snack box during the two days he/she stayed in the Evaluation Room. Further interview revealed the facility did not provide meals to any of the other patients in the Evaluation Room either.

Further review of physician orders dated 02/03/19 at 12:15 PM and 12:30 PM, while Patient #2 was still a patient of the ED in the Evaluation Room, revealed the patient's physician prescribed the following medication for Patient #2: Abilify daily (treats schizophrenia, bipolar disorder, and depression), Aspirin daily, Tenormin daily (treats high blood pressure and chest pain), Celexa daily (treats depression), and Microzide daily (treats high blood pressure and fluid retention). Further review revealed the patient's physician ordered fish oil twice daily (helps lower cholesterol) and Keppra twice daily (prevents seizures) on 02/03/19 at 10:00 PM.

Review of Patient #2's Medication Administration Record (MAR) revealed staff did not administer the following medications to the patient as ordered by the patient's physician because the "med [medication] [was] not available": Abilify was not administered on 02/03/19; Celexa was not administered on 02/03/19 or 02/04/09; and Fish Oil was not administered on 02/04/19. In addition, review of the MAR revealed Keppra was only administered one time on 02/04/19 (10:22 AM), and there was no documentation regarding why the second dose of Keppra was not administered.

Further review of Patient #2's MAR revealed Aspirin, Tenormin, nor Microzide were administered to the patient on 02/04/19 due to "held for low BP [blood pressure]." However, there was no documented evidence staff obtained the patient's blood pressure on 02/04/19.

Further review of Patient #2's medical record revealed staff documented the patient was "resting with eyes closed" in the "waiting room" on 02/02/19 from 12:45 AM to 5:15 PM on 02/03/19, with the exception of 8:45 AM, 12:15 PM, and 12:30 PM when staff documented the patient was awake. Further review revealed the patient went back to sleep on 02/03/19 from 10:15 PM until 02/04/19 at 6:00 AM, but did not go back to sleep on 02/04/19 until 3:15 AM, and slept until 8:15 AM. Continued review revealed Patient #2 was awake until 02/05/19 at 1:11 AM, when the patient was admitted to the facility, approximately three days after the patient presented to the ED for treatment.

3. Review of Patient #5's medical record revealed the patient presented to the ED on 02/03/19 at 12:33 AM with "Psychiatric Symptoms." Review of the Triage Note dated 02/03/19 at 12:33 AM revealed the patient arrived via Law Enforcement with a Mental Inquest Warrant for a seventy-two (72) hour hold. Review of the Mental Inquest Warrant revealed Patient #5 told a Licensed Clinical Social Worker (LCSW) that he/she had not been taking his/her medications and was having hallucinations and delusions. Further review revealed the patient believed someone was trying to kill him/her and had been interacting with his/her hallucinations. According to the documentation, Patient #5 had been wandering in the streets and was a danger to self and others.

Review of the "Psych Triage" dated 02/03/19 at 2:02 AM revealed Patient #2 was oriented and obeyed commands, but had racing thoughts, auditory/visual hallucinations, and delusions. In addition, the patient had an unkempt and disheveled appearance, anxious mood, anxiety, and agitation.

Further review of Patient #5's medical record dated 02/03/19 at 1:30 AM, revealed Patient #5 was seen by the Medical Director in the ED Room 17 [Evaluation Room] and was being committed on an involuntary basis.

Review of Patient #5's physician orders revealed on 02/03/19 at 12:30 PM, the patient's physician prescribed Prolixin daily (treats schizophrenia), and at 4:30 PM the physician ordered Depakote (treats seizures and bipolar disorders) twice daily for Patient #5. However, a review of Patient #5's Medication Administration Record (MAR) revealed no documented evidence staff administered Depakote on 02/03/19 (the reason was not documented) or on 02/04/19 due to "med [medication] not available." Further review revealed on 02/03/19 Prolixin was not administered due to "med not available."

An interview was attempted with Patient #5 on 02/18/19 at 3:50 PM; however, the patient did not want to speak with the State Agency Surveyor.

Further review revealed Patient #5 was not admitted until 02/04/19 at 11:16 PM, approximately twenty-four (24) hours after presentation to the ED.

4. Observation of Patient #3 on 02/11/19 at 5:00 PM, revealed the patient was lying on the floor of the Evaluation Room on a sheet with his/her head on a pillow and there were two other male patients in the room.

Review of Patient #3's medical record revealed the patient presented to the ED on 02/10/19 at 8:00 PM, approximately twenty-one (21) hours before with "Psychiatric Symptoms." Review of the Triage Note dated 02/10/19 at 8:00 PM revealed the patient arrived via Law Enforcement with hallucinations, and hearing voices telling the patient to harm himself/herself. The patient reported that he/she had swallowed the hook from an earring earlier and had been seen and treated at a primary care center.

Further review of Patient #3's medical record dated 02/10/19 at 11:33 PM revealed the Quality Mental Health Professional (QMHP) evaluated the patient and found that he/she met criteria for a psychiatric admission.

Further review of Patient #3's medical record revealed no documented evidence a lunch meal was ordered for the patient on 02/11/19 while in the Evaluation Room. Interview with Patient #3 on 02/11/19 at 5:00 PM, while the patient was lying on the floor, revealed he/she was offered a breakfast meal on 02/11/19 at 7:30 AM, but he/she did not want to eat. However, Patient #3 stated staff had not offered a lunch meal on 02/11/19. The patient stated he/she "hoped" staff would offer a meal tray that evening. During the interview at 5:10 PM, RN #14 entered the Evaluation Room and told the patients that meal trays would be arriving at 5:30 PM. When RN #14 left the Evaluation Room, unsampled Patient H stated, "You need to stay in here with us. I'm sure they would feed us with you here."

Further review of Patient #3's medical record revealed the patient was not admitted to the Psychiatric Unit until 02/11/19 at 8:09 PM, twenty-four hours after presentation to the facility's ED and nine hours after the QMHP documented that the patient met criteria for admission.

Interview with RN #14 on 02/13/19 at 1:30 PM, who was working on 02/11/19, revealed she could not remember whether Patient #3 received a lunch meal tray or if the patient did not want to eat. However, she stated she offered a meal to everyone in the room.

Interview with RN #16 on 02/14/19 at 3:20 PM revealed on 02/04/19 (when Patients #2 and #5 were in the room) there were thirteen (13) patients in the Evaluation Room and other patients were sitting outside the Evaluation Room. RN #16 revealed there was not enough space and with no beds, patients did not have a choice except to sit on the floor. Continued interview with RN #16 revealed staff had to obtain patients' medications from the ED Pyxis machine (electronic medication storage cabinet) and many commonly used psychotropic drugs and other non-emergent drugs were not available in the Pyxis. RN #16 stated he had notified the DON in the past that if patients were going to be in the Evaluation Room for more than twenty-four (24) hours, staff needed medications to be available. He stated he had also notified the facility's Pharmacy Department when medications were needed, but did not receive the medications. According to RN #16, he recalled providing Patient #2's meals and offering snacks and drinks to other patients.

Interview with RN #18 on 02/18/19 at 7:20 PM, revealed she worked in the Evaluation Room on the 7:00 PM to 7:00 AM shift and had cared for as many as approximately eight (8) patients in the room at one time. She stated patients had slept on the floor and in chairs. RN #18 further stated that in the past they had also brought in additional chairs that were not designed to be in an area with patients with behavioral health issues (e.g., chairs could be picked up and thrown). In addition, RN #18 stated there was a refrigerator in the Evaluation Room; however, there was rarely any food stocked in the refrigerator. According to RN #18, when the refrigerator was stocked, ED staff often take the food for themselves or for other patients in the ED. She stated she often notified the House Supervisor that food was needed for patients; however, if it was between 2:00 and 3:00 AM, there was no one in the Dietary Department to obtain food. RN #18 stated patients usually had to wait until 7:00 AM, for dietary staff to bring food to the Evaluation Room. Observation of the Evaluation Room refrigerator and pantry revealed during the interview with the RN, a physician came and left with the only bottle of Sprite that was stocked in the room. RN #18 stated ED staff often took food/drinks from the Evaluation Room.

Interview with RN #17 on 02/19/19 at 6:03 PM revealed he had worked in the ED Evaluation Room for two (2) years and worked the 7:00 PM to 7:00 AM shift. He stated on 02/11/19, (when Patient #3 presented) he was responsible for twelve (12) patients. Nine (9) of the patients were in the Evaluation Room, two were outside the room that did not meet criteria for admission, and one patient was being evaluated by the QMHP. He stated they brought more chairs in the room for patients to use for the night and one patient sat/slept on the floor. RN #17 stated he also recalled Patients #2 and #3 being in the Evaluation Room "for a long time." He stated he remembered that on one of the nights, there were beds available in the ED. He stated he asked House Supervisor #3 if Patients #2 and #3 could use the beds; however, the House Supervisor stated the Director of Psychiatric Services told her that the patients could not use the beds. He stated the patients pushed two chairs together and slept on the chairs. RN #17 stated patients often had to spend the night, and at times more than one night, and they just want to lie down to sleep. However, there were no accommodations for sleeping in the Evaluation Room and the patients had to lie on the floor or sleep in chairs. Further interview with RN #17 revealed the Evaluation Room refrigerator was never stocked with enough food to feed all the patients and they had to tell patients that they had to wait for breakfast to get food.

Interview with House Supervisor #3 on 02/19/19 at 7:33 PM revealed she had never been notified by the Evaluation Room nurse that the Pyxis did not have the ordered medications needed for patients in the Evaluation Room. However, she stated she would not have known what to do even if staff had notified her. She stated, "This has not been explained to me."

Interview with the Pharmacy Director on 02/19/19 at 5:15 PM revealed the ED had a pharmacist available ten (10) hours a day, seven (7) days a week, and a pharmacist was in the facility twenty-four hours a day, every day. The Pharmacy Director stated when a medication was not available in the Pyxis, Pharmacy could always supply the medication if they were notified.

Interview with the Dietary Manager on 02/19/19 at 3:13 PM revealed dietary staff stocked the Evaluation Room daily at 7:00 PM with six (6) "snack box meals" that contained a turkey sandwich, pasta salad, fruit, milk, and condiments. According to the Dietary Manager, she would supply extra snack boxes if they were needed; however, staff did not routinely ask for extra food. Further interview revealed she only routinely provided meals to patients if the patient had a physician's order for a meal.

Interview with the ED Nurse Manager on 02/11/19 at 5:20 PM and 02/13/19 at 3:15 PM, revealed the nurse in the Evaluation Room was responsible for the patients' care. She stated the nurse was responsible for administering their medications and ensuring the patients had physician's orders for food when needed. She stated ED staff also took extra meal trays to the Evaluation Room when a patient was discharged or was transferred, to share them with patients in the Evaluation Room.

Interview with the Emergency Department (ED) Director on 02/13/19 at 3:15 PM also revealed the psychiatric nurse who worked in the Evaluation Room was responsible for the care of the patients in that room. The ED Director stated he was aware patients had to stay in the Evaluation Room for an extended period at times and was aware that patients in the Evaluation Room were not supplied a bed when they had to spend the night.

Interview with the Executive Director of the Psychiatric Department on 02/20/19 at 3:40 PM revealed the Evaluation Room nurses were responsible for ordering meal trays for patients in the Evaluation Room. He stated prior to the state agency's investigation, he had not identified that patients were not receiving meals. Further interview revealed after the physician ordered a medication, nurses were responsible for ensuring the patients received their medications. He further stated nurses should notify the House Supervisor or could call the pharmacy themselves if the ordered medications were not available. He stated he was not aware patients were not receiving ordered medications while patients in the Evaluation Room. Even though the Director stated he was aware there had been patients who had spent the night in the Evaluation Room, he stated he was not aware that staff were giving the patients sheets, pillows, or blankets to sleep on the floor. Further interview revealed he recalled that a nurse asked if two patients could utilize an ED bed for the night; however, according to the Executive Director, there were no ED beds available.

Interview with the DON on 02/20/19 at 2:45 PM confirmed she was aware t

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an organized nursing service that provided twenty-four (24) hour supervision/evaluation for one (1) of ten (10) patients (Patient #1) and ensured medications were administered to two (2) of ten (10) patients (Patients #2 and #5) as ordered by their physicians. On 02/05/19, staff assessed Patient #1 and determined supervision was required every fifteen (15) minutes to monitor the patient's mental status. However, there was no documentation that the facility assessed/evaluated Patient #1 every fifteen minutes from 4:40 PM on 02/05/19 until 02/06/19 at 6:40 AM. Further, there was no documentation regarding any type of assessment/monitoring completed from 10:00 PM on 02/05/19 when the patient was evaluated by the QMHP, until 6:40 AM on 02/06/19 when the patient's supervision level was increased.

In addition, the facility failed to administer medications to Patient #2 and Patient #5 on 02/03/19 and 02/04/19 as ordered by the patients' physician.

Based on interview, record review, and review of the facility's Supervision of Patients Policy, it was determined the facility failed to supervise and evaluate the nursing care for one (1) of ten (10) sampled patients (Patient #1). Patient #1 presented to the Emergency Department (ED) on 02/05/19 and was assessed to require supervision every fifteen (15) minutes to monitor the patient's mental status. However, there was no documentation that the facility assessed/evaluated Patient #1 every fifteen minutes from 4:40 PM on 02/05/19 until 02/06/19 at 6:40 AM. There was no documentation regarding any type of assessment/monitoring completed from 10:00 PM on 02/05/19 when the patient was evaluated by the QMHP, until 6:40 AM on 02/06/19 when the patient's supervision level was increased.

The findings include:

Review of the facility's Supervision of Patients Policy, dated March 2017, revealed the facility's policy was to provide adequate monitoring consistent with patient safety. The policy stated patients would receive the appropriate level of supervision to maintain care, welfare, safety, and security of all patients and staff.

Review of Patient #1's medical record revealed the patient presented to the ED via Emergency Medical Services (EMS) on 02/05/19 at 4:26 PM from a nursing facility (nursing home) due to an involuntary petition for a behavioral health evaluation. According to the Triage Assessment dated 02/05/19 at 5:02 PM, Patient #1 presented with diagnoses of "Schizophrenia, Bipolar Disorder, and Anxiety, and other mental illness." The assessment stated the patient was "Physically and verbally abusive toward staff and others, kicking, pinching, biting, pulling hair, and wrapped arms and legs around employee and tried to bite her." In addition, the form stated Patient #1 "threatens to kill others and cause them physical harm."

Review of Patient #1's "Psych Intake" notes dated 02/05/19 at 4:40 PM revealed the patient stated, "I suppose I need a bed here" when asked about his/her expectations of treatment. The notes stated the patient was disoriented, restless, cooperative, anxious, restless, and impulsive. Further review revealed Patient #1 had moderately impaired comprehension and mildly impaired oral ability. Review of the Psychiatric Suicide Risk Assessment completed during the "Psych Intake" revealed the patient was at low risk for suicide, but required fifteen-minute checks to be documented to assess and monitor for mental status changes.

Further review of Patient #1's medical record revealed staff documented that lab specimens were obtained on 02/05/19 at 4:56 PM, 5:11 PM, and 5:19 PM. Continued review revealed at 10:00 PM on 02/05/19 the Qualified Mental Health Professional (QMHP) evaluated the patient and the patient did not meet the criteria for an admission to the behavioral health unit. However, there was no documented evidence that the facility assessed/evaluated Patient #1 every fifteen minutes from 02/05/19 at 4:40 PM, when the patient was assessed to require supervision, until 02/06/19 at 6:40 PM, when the patient's supervision was increased to every seven (7) minutes (reason for the increase was not documented). In addition, there was no documentation regarding any type of assessment from 10:00 PM on 02/05/19, when the patient was evaluated by the QMHP until 6:40 AM on 02/06/19, when the patient's supervision level was increased.

Interview with RN #18 on 02/18/19 at 7:20 PM revealed she cared for Patient #1 during the night of 02/05-06/19 and monitored the patient every fifteen (15) minutes as required. The RN stated the patient remained in a chair in the Evaluation Room all night and was calm. However, there was no documented evidence that the RN supervised/evaluated the patient.

Interview with the Director of Nursing on 02/12/19 at 5:35 PM and the Executive Director of the Psychiatric Unit on 02/13/19 at 5:40 PM revealed staff were required to monitor Patient #1 every fifteen (15) minutes, but they were unable to locate documentation that the monitoring had been conducted.

Based on interview, record review, and review of facility policy, it was determined that the facility failed to administer medication to two (2) of ten (10) patients (Patients #2 and #5) as ordered by the patients' physicians. Patients #2 and #5 presented to the Emergency Department (ED) and their physicians ordered medications to be administered to the patients. However, the facility failed to administer the patients' medications.

The findings include:

Review of the facility's policy titled "Medication Administration," dated 01/02/07, revealed medications should be ordered by a credentialed, licensed independent practitioner and should be administered by a healthcare professional registered to do so in the state where they were practicing. Further review of the policy revealed medication safety and administration was a joint effort between the Pharmacy Department and the Nursing Department.

1. Review of Patient #2's ED medical record revealed the patient presented to the ED on 02/02/19 at 8:26 PM with "Psychiatric Symptoms." Review of the Triage Assessment dated 8:27 PM revealed the patient arrived via Law Enforcement and was "here on a uniform citation. Per citation, patient told officer that when [the patient] got home [the patient] wanted to kill {him/her] self and also walked in traffic this evening. Patient states that [he/she] went home and someone started picking on [him/her] and calling [him/her] a rat and [he/she] didn't want to stay there so [he/she] told the officer [he/she] wanted to kill self."

Further review of Patient #2's medical record revealed on 02/02/19 at 10:35 PM, a physician assessed Patient #2. The evaluation stated he saw and examined the patient in the psychiatric area room [Evaluation Room] for suicidal ideation and vague homicidal thoughts. The patient also had auditory and visual hallucinations, exhibited paranoia that his/her neighbors were out to get him/her, and stated he/she used methamphetamine. According to the note, the QMHP had also evaluated the patient and the recommendation was to place the patient under a 72-hour hold because the patient "did not have the mental capacity to be able to voluntarily commit [him/her] self."

Further review of physician orders dated 02/03/19 at 12:15PM and 12:30 PM, while Patient #2 was still a patient of the ED in the Evaluation Room, revealed the patient's physician prescribed the following medication for Patient #2: Abilify daily (treats schizophrenia, bipolar disorder, and depression), Aspirin daily, Tenormin daily (treats high blood pressure and chest pain), Celexa daily (treats depression), and Microzide daily (treats high blood pressure and fluid retention). Further review revealed the patient's physician ordered fish oil twice daily (helps lower cholesterol) and Keppra twice daily (prevents seizures) on 02/03/19 at 10:00 PM.

Review of Patient #2's Medication Administration Record (MAR) revealed Registered Nurse (RN) #16 documented the following medications were not administered to the patient as ordered by the patient's physician because the "med [medication] [was] not available": Abilify was not administered on 02/03/19; Celexa was not administered on 02/03/19 or 02/04/09; and Fish Oil was not administered on 02/04/19. In addition, review of the MAR revealed Keppra was only administered one time on 02/04/19 (10:22 AM), and there was no documentation regarding why the second dose of Keppra was not administered.

Further review of Patient #2's MAR revealed RN #16 documented that Aspirin, Tenormin, nor Microzide were administered to the patient on 02/04/19 due to "held for low BP [blood pressure]." However, there was no documented evidence staff obtained the patient's blood pressure on 02/04/19.

Continued review of Patient #2's medical record revealed the patient was not admitted to the Psychiatric Unit until 02/05/19 at 1:11 AM, approximately three days after the patient presented to the ED for treatment. Review of the patient's history and physical (H&P) dated 02/05/19 revealed the patient's blood pressure was 119/81 at 7:26 AM after the patient was admitted, which was "H [high]" according to the H&P.

Interview with Patient #2 on 02/11/19 at 1:22 PM revealed he/she was in the evaluation room for two days and two nights and did not receive all the medications that he/she was normally prescribed to take at home.

2. Review of Patient #5's medical record revealed the patient presented to the ED on 02/03/19 at 12:33 AM with "Psychiatric Symptoms." Review of the Triage Note dated 02/03/19 at 12:33 AM revealed the patient arrived via Law Enforcement with a Mental Inquest Warrant (MIW), for a seventy-two (72) hour hospitalization. Review of the MIW revealed Patient #5 told a Licensed Clinical Social Worker (LCSW) that he/she had not been taking his/her medications and was having hallucinations and delusions. Further review revealed the patient believed someone was trying to kill him/her and had been interacting with his/her hallucinations. According to the documentation, Patient #5 had been wandering in the streets and was a danger to self and others.

Review of the "Psych Triage" dated 02/03/19 at 2:02 AM revealed the patient had racing thoughts, auditory/visual hallucinations, and delusions; had an unkempt and disheveled appearance; anxious mood; and had anxiety and agitation.

Further review of Patient #5's medical record dated 02/03/19 at 1:30 AM, revealed Patient #5 was seen by the Medical Director in ED Room 17 [Evaluation Room] and was being committed on an involuntary basis.

Review of Patient #5's physician orders revealed on 02/03/19 at 12:30 PM, while Patient #5 was still a patient at the ED in the Evaluation Room, the patient's physician prescribed Prolixin daily (treats schizophrenia), and at 4:30 PM, the physician ordered Depakote (treats seizures and bipolar disorders) twice daily for Patient #5. However, a review of Patient #5's Medication Administration Record (MAR) revealed no documented evidence that staff administered Depakote on 02/03/19 (the reason was not documented) or on 02/04/19 due to "med [medication] not available." Further review revealed on 02/03/19 Prolixin was not administered due to "med not available."

An interview was attempted with Patient #5 on 02/18/19 at 3:50 PM; however, the patient did not want to speak with the State Agency Surveyor.

Interview with the Pharmacy Director on 02/19/19 at 5:15 PM revealed a pharmacist was available for the ED ten (10) hours a day, seven (7) days a week. In addition, a pharmacist was available at the facility twenty-four hours a day, every day. The Pharmacy Director stated when a medication was not available in the Pyxis, Pharmacy could always supply the medication if they were notified.

Interview with Registered Nurse (RN) #16 on 02/14/19 at 3:20 PM revealed staff had to obtain patients' medications from the ED Pyxis machine (electronic medication storage cabinet). However, he stated many commonly used psychotropic drugs and other non-emergent drugs were not available in the Pyxis. RN #16 stated he had notified the Director of Nursing (DON) in the past that if patients were going to be in the Evaluation Room for more than twenty-four (24) hours, staff needed medications to be available. He stated he had also notified the facility's Pharmacy Department when medications were needed, but either did not receive the medications or it took a long time to obtain the medications.

Interview with RN #17 on 02/19/19 at 6:03 PM also revealed some medications were not available in the ED Pyxis and he had to obtain the medication from pharmacy. He stated Pharmacy would bring the medication, but "sometimes you have to wait a long time."

Interview with the DON on 02/20/19 at 2:45 PM confirmed she was aware that commonly prescribed psychoactive maintenance medications were not available in the ED. She stated she had talked with the Pharmacy Department concerning stocking the Pyxis (electronic medication storage cabinet) with psychoactive drugs commonly prescribed for maintenance of behavioral health symptoms. However, she stated nurses were required to notify the House Supervisor when they did not have access to ordered medications in the ED.

Interview with House Supervisor #3 on 02/19/19 at 7:33 PM revealed she had never been notified by the Evaluation Room nurse that the Pyxis did not have the ordered medications needed for patients in the Evaluation Room. However, she stated she would not have known what to do even if staff had notified her. She stated, "This has not been explained to me."

Based on observation, interview, record review, review of the facility's policies/procedures, and review of the Centers for Disease Control and Prevention guidelines, it was determined the facility failed to ensure an infection control program was developed and implemented to ensure the identification, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel. The facility failed to implement their own policies and procedures related to controlling the spread of infections in the facility, failed to ensure patients were placed on appropriate infection control precautions, failed to ensure staff and visitors were made aware when patients required infection control practices, failed to ensure staff practiced appropriate infection control procedures, and failed to ensure all staff providing care to facility patients had received appropriate training and education specific to the facility's infection control program.

Based on observation, interview, record review, review of the facility's policies/procedures, and review of the Centers for Disease Control and Prevention guidelines, it was determined the facility failed to ensure an infection control system was developed and implemented for two (2) of ten (10) sampled patients (Patient #4 and Patient #6) and seven (7) unsampled patients (Patients A, B, C, D, E, F, and G) to ensure identification, reporting, investigation, and controlling of infections and communicable diseases of patients and facility personnel.

The facility admitted Patient #4 on 11/21/18, with diagnoses of Schizophrenia, Cerebrovascular Accident, Hypertension, and Atrial Fibrillation. On 01/17/19, the patient was diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA) in the blood and sputum. Subsequently, Patient #4 was transferred to a private room. However, according to interviews with facility staff, Patient #4's Guardian, and visitors of Patient #4, the facility failed to implement appropriate infection control procedures and failed to provide education to family and visitors regarding utilizing infection control precautions when visiting patient #4. Although Patient #4 was discharged from the facility to a skilled nursing facility on 02/08/19, the patient was readmitted back to the facility on 02/09/19, less than twenty-four hours after discharge with diagnoses including Healthcare-Associated Pneumonia, which the facility was treating with Vancomycin (an antibiotic used to treat drug resistant bacteria). However, the facility failed to implement appropriate infection control measures for Patient #4, including alerting staff and visitors of the need to utilize infection control precautions. Observations of Patient #4 on 02/11/19 at approximately 11:40 AM revealed the patient was receiving IV Vancomycin and Zosyn (a Penicillin antibiotic used to treat infections). However, further observation revealed there was no signage outside the patient's door or anywhere adjacent to the patient's room indicating the patient was on infection control precautions.

Review of Patient #6's medical record revealed the facility admitted the patient on 02/05/19, with diagnoses including End Stage Renal Disease, Acute Dehydration, and Diabetes. Observation of Patient #6 on 02/12/19 at 11:10 AM, revealed contact precaution signage was hanging outside of the patient's door; however, Registered Nurse (RN) #1 was in the patient's room, but was not wearing gloves or a gown, the required Protective Personal Equipment (PPE) to be worn when a patient was on contact precautions. Further observations revealed RN #1 exited Patient #6's room without washing his hands or utilizing the antimicrobial hand sanitizer, which was located outside of Patient #6's room.

In addition, seven (7) unsampled patients who were required to be on contact precautions per the facility's policies and procedures were observed on 02/12/19, without the precautions in place. Furthermore, observations and facility documentation revealed thirty-three (33) contracted nursing staff and only three (3) full-time facility employed nurses staffed the Three West Unit of the facility. However, interviews with staff and review of employee files revealed the contracted nurses were not consistently receiving appropriate continuing education and training related to the specifics of the facility's infection control program.

The findings include:

Review of the facility's policy, "Standard and Transmission Precautions," dated March 2018, revealed all healthcare workers would comply with infection prevention and procedures guidelines. The policy stated infection control precautions would be implemented to reduce the risk and transmission of infection by direct or indirect contact. The policy defined direct contact transmission as skin-to-skin contact between the patient and the healthcare worker and indirect contact transmission as skin contact with a fomite (bed rail, food tray, television remote, etc.) and then transferred to the healthcare worker or next patient admission when the fomite is touched.

Continued review of the "Standard and Transmission Precautions" policy revealed any patient with a history of Methicillin Resistant Staphylococcus Aureus (MRSA) or any MDRO (Multi-Drug Resistant Organism) would be isolated with appropriate precautions implemented as if the patient had an active current diagnosis. The policy stated nursing staff and the Infection Control Preventionist (ICP) had the authority to implement infection control precautions. Further review of the policy revealed staff would document the reason for instituting infection control precautions for each patient and place the appropriate signage on the patient's room door.

In addition, the "Standard and Transmission Precautions" policy stated staff would explain to the patient and their visitors the reason for the patient being placed on contact precautions and how it would affect them. In addition, staff would provide an educational handout to the patient/visitor and document the education. Continued review of the policy revealed gloves and a gown were required to be worn when entering a patient's room when contact precautions were warranted, and the gloves and gown would be removed prior to exiting the patient's room. Furthermore, staff would perform hand hygiene upon exiting the patient's room with soap and water or an alcohol-based hand rub.

Review of the Centers for Disease Control and Prevention "Healthcare Settings, Preventing the Spread of MDROs" revealed in healthcare facilities, such as hospitals, a Multi-Drug Resistant Organism (MDRO) could cause severe problems including bloodstream infections, pneumonia, surgical site infections, sepsis, and death. The guideline stated MDROs are usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers. In addition, people who carry a MDRO but do not have signs of infection can spread the bacteria to others. The guidelines further stated that numerous studies have demonstrated that MDRO prevention efforts could reduce infections, but required action at the healthcare facility level, among healthcare providers, and healthcare leadership. The guidelines further stated that healthcare facilities should make prevention of MDRO infections a priority, assess their relevant data, implement prevention actions, and evaluate progress.

1. Review of Patient #4's medical record revealed the facility admitted the patient on 11/21/18 with diagnoses of Schizophrenia, Cerebrovascular Accident, Hypertension, and Atrial Fibrillation. Review of the patient's History and Physical dated 11/21/18 revealed an outside facility transferred the patient to the facility due to aggressive and combative behavior. The facility admitted the patient for further medical treatment due to the patient's diagnosis of a low heart rate while in the Emergency Room.

Further review of the patient's medical record for the 11/21/18 admission revealed the results of blood cultures obtained on 01/17/19 at 9:37 AM, with a final report date of 01/20/19, revealed Patient #4 had Methicillin Resistant Staphylococcus Aureus (MRSA, a bacteria that is resistant to multiple drugs). Review of a bilateral Bronchial Wash (a procedure where cells are taken from inside the airway) performed on Patient #4 on 01/17/19 at 10:50 AM, with a final report date of 01/19/19, revealed a heavy growth of MRSA.

Continued review of Patient #4's medical record for the 11/21/18 admission, revealed the facility diagnosed the patient with MDRO pneumonia and placed the patient on intravenous (IV) Vancomycin (an antibiotic used to treat severe life-threatening bacterial infections caused by susceptible strains of methicillin-resistant staphylococci). In addition, the patient was transferred to a private room on the Telemetry Unit. Review of the final report dated 01/21/19 of the blood cultures obtained on 01/19/19, revealed Gram Positive Cocci and Coagulase Negative Staphylococcus (the most common cause of nosocomial bloodstream infections).

Interview with RN #3 on 02/13/19 at 3:13 PM, revealed that she was Patient #4's nurse when the patient was transferred to the Telemetry Unit on 01/19/19. RN #3 stated the patient had been on the floor for a "couple of hours" and she stated she had "wallowed all over" the patient before she found out the patient should have been on contact precautions. RN #3 stated she found out the patient was on contact precautions while looking through the patient's transfer papers a couple of hours after the patient was transferred to her unit. RN #3 stated she routinely learned of patients who required contact precautions based on the MDRO report that printed each day. However, she stated Patient #4's report was printed on the unit the patient was transferred from. The nurse stated she could not recall the nurse on the transferring unit telling her that Patient #4 required contact precautions. RN #3 stated the only way she would know a patient was on contact precautions if she was not present when the MDRO report printed was to observe for signage posted at the patient's door. RN #3 stated at that time she placed a contact precautions sign outside of the patient's door once she became aware that the patient was on contact precautions. However, interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed she visited Patient #4 approximately one (1) hour and twenty (20) minutes after the patient was transferred to the Telemetry Unit on 01/19/19, and there was no contact precaution signage posted at the patient's door. However, Patient #4 stated that RN #3 told the patient that he/she had MRSA in the blood and nose.

Continued interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed the Guardian voiced a grievance to the Community Chief Regulatory Affairs Officer (CCRAO) on 01/20/19, regarding Patient #4 being transferred to the Telemetry Unit without her being informed and that although the patient had been diagnosed with MRSA, no contact precaution signage was posted at the patient's door. However, further interview with the Guardian revealed she visited Patient #4 at the facility on 01/21/19, 01/22/19, 01/24/19, and 01/27/19 and the patient still had no infection control precautions posted. Further interview with Patient #4's guardian revealed the facility did not post contact precaution signage at Patient #4's door until 01/27/19.

Continued interview with Patient #4's Guardian on 02/09/19 at 12:53 PM and 02/12/19 at 3:18 PM, revealed the Guardian stated facility staff never educated her on appropriate precautions to utilize when visiting Patient #4. In addition, the Guardian stated she had only observed one (1) staff member utilizing PPE during Patient #4's hospitalization from 01/17/19 (when the patient was first identified to have MRSA) through 02/08/19, when the patient was discharged from the facility to a skilled nursing facility.

Review of Patient #4's current medical record revealed the facility readmitted the patient on 02/09/19 (less than twenty-four hours after being discharged) with diagnoses including Healthcare-Associated Pneumonia. Review of Physician orders for Patient #4 revealed upon admission the patient was ordered to receive IV Vancomycin.

Observation of Patient #4 on 02/11/19 at approximately 11:40 AM revealed the patient was receiving IV Vancomycin and Zosyn (a Penicillin antibiotic used to treat infections). However, further observation revealed there was no signage outside the patient's door or anywhere adjacent to the patient's room indicating the patient was on infection control precautions.

Subsequent observation of Resident #4 on 02/12/19, at 3:18 PM revealed signage had been posted outside the patient's door indicating the patient was on contact precautions.

Interview with Nurse Aide (NA) #1 on 02/12/19 at 5:32 PM revealed she worked with Patient #4 on 02/09/19, 02/10/19, and 02/12/19 and the patient had not been on contact precautions until 02/12/19, "about an hour ago." NA #1 stated she had provided care to Patient #4 for three (3) days without observing contact precautions. NA #1 stated approximately one hour ago she had been told Patient #4 "might have MRSA," however they were not sure yet. NA #1 stated she became aware that the patient was on contact precautions when she observed signage had been placed outside of the patient's door. NA #1 stated infection control precautions for patients was not discussed in shift report, and the only way to know that precautions were to be followed was if signage was posted outside the patient's door.

Interview with RN #2 on 02/12/19 at 4:56 PM revealed she had been the nurse caring for patient #4 on 02/11/19, but had been unaware the patient was required to be on contact precautions. RN #2 stated the patient was being treated with IV Vancomycin and IV Zosyn due to a diagnosis of pneumonia, and was unaware if Patient #4 had a current active MRSA infection. Continued interview with RN #2 revealed that if a patient was on contact precautions, staff were expected to wear a gown and gloves when entering the patient's room. RN #2 stated the floor nurse was responsible for placing contact precaution signage outside of a patient's room when a positive Multi-Drug Resistant Organism (MDRO) was identified. However, RN #2 stated if the MDRO was identified prior to the patient arriving on the floor, she would have no way of knowing that unless she was notified by facility personnel who knew of the diagnosis.

Interview with RN #5 on 02/18/19 at 5:53 PM revealed she had provided care for Patient #4 after being readmitted to the facility on 02/09/19. However, RN #5 stated she was not aware of the patient ever being on contact precautions. RN #5 stated if the patient had been on contact precautions, there would have been contact precautions signage next to the patient's door.

Interview with RN #4 on 02/18/19 at 3:57 PM revealed she had worked with Patient #4 after the patient's readmission to the facility on 02/09/19. However, there had been no signage placed outside the patient's door, and she had not utilized contact precautions. RN #4 stated she had asked other staff if the patient was on precautions; however, no one knew. RN #4 stated that she usually found out days later that a patient was supposed to have been on contact precautions.

Interview with Case Worker #1 on 02/20/19 at 1:36 PM revealed he had visited Patient #4 in the patient's room on 02/07/19 and there was no signage posted for contact precautions outside of the patient's room.

Interview with an Admissions Coordinator (AC) from another facility on 02/20/19 at 2:26 PM revealed she met Patient #4's Guardian on 02/08/19 in the patient's room. She stated there was no contact precautions signage outside of the patient's room, and she asked the nurse caring for the patient if the patient was on contact precautions and the nurse did not know. According to the AC, the nurse stated she would have to ask someone else. The AC stated the nurse returned to the patient's room without utilizing PPE and informed them that the patient was on contact precautions.

Interview with an Adult Protective Services (APS) Worker on 02/20/19 at 12:35 PM revealed she met with the patient's Guardian on 02/08/19 in Patient #4's room, and there was no indication that the patient was on contact precautions. She stated that there was no signage outside of the patient's door and that the patient's nurse had entered the patient's room multiple times without wearing PPE.

Interview with the Infection Control Preventionist (ICP) on 02/18/19 at 3:08 PM, revealed when the facility readmitted Patient #4 on 02/09/19, the patient should have immediately been placed on contact precautions due to the recent diagnosis of MRSA on 01/17/19. The ICP stated that once a patient was diagnosed with a MDRO they were placed on contact precautions and would continue to be on contact precautions until the patient had three (3) consecutive negative cultures.

Interview with Physician #7 who was caring for Patient #4 revealed the facility should have immediately placed Patient #4 on contact precautions upon readmission to the facility on 02/09/19. The physician stated that due to the patient's diagnosis of MRSA on 01/17/19, during a previous hospitalization, the patient would require contact precautions until three (3) consecutive negative cultures were obtained, which the physician stated had not occurred.

2. Review of Patient #6's medical record revealed the facility admitted the patient on 02/05/19 with diagnoses including End Stage Renal Disease, Acute Dehydration, and Diabetes. Review of a physician's order for Patient #6 dated 02/06/19 at 10:40 AM, revealed an order to culture the resident's urine STAT (immediately).

Review of a Urinalysis Report dated 02/06/19 at 10:40 AM revealed evidence of a bacterial infection. Review of the final urine culture dated 02/09/19, for the specimen collected on 02/06/19, revealed Escherichia Coli (bacteria that normally lives in the intestines) greater than 100,000 was present in the patient's urine.

Review of Physician's Orders dated 02/06/19 at 10:30 AM revealed an order for Meropenem (a broad-spectrum antibiotic used to treat severe infections).

Observation of Patient #6 on 02/12/19 at 11:10 AM, revealed contact precaution signage was hanging outside of the patient's door; however, Registered Nurse (RN) #1 was in the patient's room, but was not wearing gloves or a gown, the required Protective Personal Equipment (PPE) to be worn when a patient was on contact precautions. Further observations revealed RN #1 exited Patient #6's room without washing his hands or utilizing the antimicrobial hand sanitizer, which was located outside of Patient #6's room.

Interview with RN #1 on 02/12/19 at 2:44 PM revealed he was "not sure" why Patient #6 was on contact precautions. Further interview with RN #6 revealed he stated he would only wear gloves when administering the resident medications or he would wear a gown and gloves if changing the resident's bed linen.

3. Observations on 02/12/19, of the Three West Unit revealed eight (8) patients admitted to the floor had signage posted indicating the patients required contact precautions.

Subsequent observations of the Three West Unit on 02/13/19 revealed the facility had placed seven (7) additional patients (unsampled Patients A, B, C, D, E, F, and G) on contact precautions. However, none of the patients were new admissions and all the patients had been present on the unit during observations on 02/12/19.

(A) Review of Patient A's medical record revealed the facility admitted the patient on 10/23/18. Review of a Microbiology Report for the patient dated 02/01/19, revealed an Anal/Rectal culture collected on 01/30/19 at 5:06 PM, which indicated Patient A had Extended Spectrum Beta-Lactamase (ESBL)[an enzyme produced by bacteria that breaks down antibiotics], Klebsiella (a gram negative bacteria), and Vancomycin Resistant Enterococcus (VRE) Faecium (a bacteria resistant to Vancomycin). Further review of the report revealed Patient A also had a Positive Hepatitis B Surface Antibody Concentration on 02/02/19. However, the facility did not place the patient on contact precautions until 02/13/19.

(B) Review of Patient C's medical record revealed the facility admitted the patient on 01/29/19. Review of a Microbiology Report of a urine culture collected on 02/06/19 with a final report date of 02/10/19 revealed Enterococcus Faecium (a Vancomycin resistant bacteria) greater than 100,000 was present in the patient's urine. A subsequent microbiology report of a urine culture collected on 02/10/19 with a final report date of 02/12/19, revealed Enterococcus Faecium 60,000 - 70,000 was present in the patient's urine. However, the facility did not place the patient on contact precautions until 02/13/19.

(C) Review of medical records revealed the facility admitted Patient B on 02/08/19, Patient D on 02/01/19, Patient E on 01/26/19, Patient F on 02/11/19, and Patient G on 02/11/19. Review of the patient's medical records revealed no microbiology reports that warranted the use of contact precautions. However, interview with the Community Chief Regulatory Affairs Officer on 02/20/19 at 4:39 PM revealed each of the patients had a history of a MDRO infection, and should have been placed on contact precautions when admitted to the facility. However, the facility failed to place any of the patients on contact precautions until 02/13/19.

Interview with RN #4 on 02/18/19 at 3:57 PM revealed that patients that required contact precautions were not communicated well with staff. She stated she worked with Patient #4 after he/she was diagnosed with MRSA and the patient did not have contact precaution signage outside of his/her door. She stated she asked other staff if the patient was on precautions; however, no one knew. RN #4 stated that she usually found out days later that a patient was supposed to be on contact precautions. If a patient was on contact precautions staff should utilize a gown and gloves when in the patient's room.

Interviews with RN #5 on 02/18/19 at 5:53 PM, RN #7 on 02/19/19 at 12:30 PM, RN #8 on 02/19/19 at 12:35 PM, and RN #11 on 02/20/19 at 11:47 AM revealed all the nurses stated that they were not always made aware of patients on contact precautions. The nurses stated that unless there was signage outside of a patient's door they did not implement contact precautions for patients. The nurses stated there was often confusion as to whether a patient required contact precautions or not, and if a patient was on contact precautions it was not always clear why.

Interviews with Environmental Services (EVS) Technician #1 on 02/19/19 at 7:20 PM and EVS Technician #2 at 12:41 PM revealed the only way they knew if a patient was on contact precautions was if a sign was placed outside the patient's door. The EVS Technicians stated they both knew of times (unable to give exact date) when a patient was supposed to have been on infection control precautions, but there had not been a sign on the door, and they had not provided the appropriate cleaning in the rooms.

4. Review of the Nursing Orientation Checklist for Registered Nurses and Licensed Practical Nurses revealed the orientation related to infection control included the following: how to don and remove personal protective equipment, obtaining routine cultures, proper disposal of sharp instruments and bodily fluids, the classification of multi-drug resistant organisms, central line infections, catheter-associated urinary tract infections, and surgical site infection prevention. However, the orientation training did not address who was responsible for determining when infection control precautions were warranted, who was responsible to ensure the appropriate infection control precautions were implemented, or who was responsible to ensure appropriate signage was placed alerting staff and visitors that infection control precautions were in place. In addition, the orientation did not address who was responsible to notify the patient/patient representative that an infection had been diagnosed or who was responsible to provide education to the patient/patient representative regarding infection control measures.

Review of a facility-generated report dated 02/19/19 revealed on the Three West Unit, the facility utilized the services of thirty-three (33) contracted nursing staff and had only three (3) full-time facility employed nurses staffed on the unit.

Interview with RN #3 on 02/13/19 at 3:13 PM revealed she was a contract nurse at the facility. RN #3 stated she had attended the facility's orientation class when she first signed her contract with the facility in 2016, but had not completed any further training at the facility. Review of RN #3's hospital training file revealed there was no evidence the employee had attended any facility trainings since orientation including any training related to infection control procedures practiced at the facility.

Interview with RN #4 on 02/18/19 at 3:57 PM revealed she was a contract nurse but had not completed any additional trainings at the facility since she had completed orientation when she first signed a contract with the facility. Review of RN #4's hospital training file revealed she had not attended any facility trainings since completing orientation in 2017, including any training related to infection control procedures practiced at the facility.

Interview with RN #6 on 02/18/19 at 7:35 PM, revealed she attended the facility's orientation when she first signed a contract to work at the hospital, but had attended no other trainings. Review of RN #6's hospital training file revealed she had not had any trainings at the facility since her orientation in 2016, including any training related to infection control procedures practiced at the facility.

Interview with RN #11 on 02/20/19 at 11:47 AM revealed she had signed multiple contracts with the facility in the past but had only attended one orientation class over a year ago. RN #11 stated she had attended no other trainings at the facility including any training related to infection control procedures practiced at the facility.

Interview with RN #12 on 02/19/19 at 2:21 PM, revealed she had worked at the facility on several occasions as a contract employee, but stated she had only attended one orientation training in October 2018, and had attended no other trainings, including any training related to infection control procedures practiced at the facility.

Interview with the Director of Quality Improvement (DQI) on 02/19/19 at 7:43 PM revealed contracted agency staff did not receive the same training as full-time staff unless they had been at the facility for an "extended period." She stated when an agency nurse started at the facility, the nurse provided the facility with a copy of their competencies through the agency company that they worked for. The DQI stated that every employee went through an orientation class at the facility prior to working on the floor. However, the DQI was unable to state how the facility ensured contract staff were made aware of updated policies/procedures in the facility or the basic working procedures in the facility such as what procedures are used when a patient is identified to have a communicable disease, how a patient requiring contact precautions is provided those precautions, what constituted contact precautions in the facility, where contact precaution signage was kept, and the nurse's role in the facility to ensure infection control policies and procedures are appropriately implemented.

Interview with the Infection Control Preventionist (ICP) on 02/18/19 at 3:08 PM revealed a facility-wide infection control training with return demonstration was conducted once yearly at the facility. Between yearly trainings, the ICP stated he conducted random rounds to ensure patients that were supposed to be on contact precautions had the appropriate signage in place and that staff were utilizing the correct personal protective equipment (PPE). However, he stated he had identified concerns with signage not being in place and staff not wearing PPE while in patient rooms when contact precautions were in place. He stated when he found issues with signage not being posted or staff not wearing PPE, he conducted on the spot training with the particular staff involved. However, he stated he had not conducted any recent facility-wide infection control trainings and did not have a system for following up with staff who had received on-the-spot training to ensure the training had been effective. The ICP stated the facility had implemented a new computer system on 02/01/19. The ICP stated the old system compiled a daily MDRO report, which was sent to each unit that detailed each patient that was on infection control precautions. However, the ICP stated the new system did not generate the same report. The ICP stated the new system also had a specific area that staff had to enter data into in order for the system to indicate that the patient should be on infection control precautions. However, according to the ICP, staff were not entering the data correctly and therefore patients that were required to be on infection control precautions were not being placed on the precautions. Further interview with the ICP revealed he was not aware of the training requirements for contract staff working at the facility.

Based on observation, interview, and record review, it was determined the facility failed to meet the needs of Emergency Department (ED) patients in accordance with acceptable standards of practice. Observation and interview revealed patients who presented to the ED (male and female) with behavioral health concerns were not provided with a bed in the ED, but were taken to an approximately 199 square foot room located within the ED for evaluation and treatment. Interview and record review revealed patients sometimes had to wait in the room, that was furnished with six (6) chairs and had no beds, for more than twenty-four (24) hours when inpatient psychiatric beds were not available or patients had no transportation available to leave the ED. Observation and interview revealed the facility failed to have an effective system for ensuring food and medications were available and provided to patients while in the Evaluation Room. Interview and record review revealed Patients #1, #3, and #5 spent more than twenty-four hours in the ED Evaluation Room, and Patient #2 spent approximately more than two days in the room. The facility failed to ensure Patients #1, #2, and #3 received meals/snacks while being held in the room. In addition, the facility failed to administer medications to Patients #1, #2, and #5 (refer to A1103).

Further, the facility failed to establish a policy/procedure regarding care and treatment for patients in the Evaluation Room. Review of the facility's ED log and a list of patients provided by the facility, revealed from 02/01/19 through 02/13/19, there had been approximately fourteen (14) patients assigned to the room at one time. Further review revealed twelve (12) patients stayed in the ED Evaluation Room for approximately/more than twenty-four (24) hours, even though the room was not furnished with beds. Subsequently, interviews with staff and patients revealed patients had no other choice but to sleep in a chair or on the floor when they were held in the ED Evaluation Room (refer to A1104).

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure emergency services were integrated with other departments of the facility. Observation and interview revealed the facility failed to have an effective system for ensuring food and medications were available and provided to patients in the Emergency Department (ED) Evaluation Room. Interview and record review revealed Patients #1, #3, and #5 spent more than twenty-four hours in the ED Evaluation Room, and Patient #2 spent approximately three days in the room. The facility failed to ensure Patients #1, #2, and #3 received meals/snacks while being held in the room. In addition, the facility failed to administer medications to Patients #1, #2, and #5. Staff documented that most of Patient #2 and #5's medications were not available.

The findings include:

Review of the facility's policy titled "Patient Care Flow Record," dated 10/01/05, revealed patient food intake should be documented; however, the policy did not address the policy/procedure for ordering/obtaining food for patients in the ED Evaluation Room. Interview with the Director of Nursing (DON) on 02/12/19 at 2:50 PM, and on 02/20/19 at 2:45 PM revealed if a patient's physician did not order a meal for the patient, nursing staff was responsible for notifying the physician and obtaining an order for meals. In addition, the DON stated staff were responsible for documenting how much a patient ate or if the patient refused to eat.

Review of the facility's policy titled "Medication Administration," dated 01/02/07, revealed medications should be ordered by a credentialed, licensed independent practitioner and should be administered by a healthcare professional registered to do so in the state where they were practicing. Further review of the policy revealed medication safety and administration was a joint effort between the Pharmacy Department and the Nursing Department. The policy did not address the procedure for obtaining medications for patients who were in the ED Evaluation Room.

1. Review of Patient #2's ED medical record revealed the patient presented to the ED on 02/02/19 at 8:26 PM with "Psychiatric Symptoms."

Further review revealed on 02/02/19 at 10:35 PM, Patient #2's physician documented that the patient had suicidal ideation and vague homicidal thoughts. The patient also had auditory and visual hallucinations, exhibited paranoia that his/her neighbors were out to get him/her, and used methamphetamine. According to the note, the Qualified Mental Health Professional had also evaluated the patient and the recommendation was to place the patient under a 72-hour hold because the patient "did not have the mental capacity to be able to voluntarily commit [him/her] self."

However, interview with the Executive Director of the Psychiatric Unit on 02/11/19 at 12:40 PM revealed there was no inpatient bed available for the patient.

Review of Patient #2's Physician orders dated 02/03/19 at 3:26 AM revealed an order to admit the patient and to provide a regular diet for the patient. According to the patient's medical record, nursing staff ordered a regular diet for the patient while in the Evaluation Room. However, there was no documented evidence that staff documented how much the patient ate. Interview with Patient #2 on 02/11/19 at 1:22 PM revealed he/she did not receive a meal while in the Evaluation Room and "had to beg for food" and for something to drink. Patient #2 stated he/she only got one snack box during the two days he/she stayed in the Evaluation Room. Further interview revealed the facility did not provide meals to any of the other patients in the Evaluation Room either.

Further, review of Patient #2's Medication Administration Record (MAR) revealed staff did not administer the following medications to the patient as ordered by the patient's physician because the "med [medication] [was] not available": Abilify (treats schizophrenia, bipolar disorder, and depression) was not administered on 02/03/19; Celexa (treats depression) was not administered on 02/03/19 or 02/04/09; and Fish Oil (helps lower cholesterol) was not administered on 02/04/19. In addition, review of the MAR revealed Keppra (prevents seizures) was only administered one time on 02/04/19 (10:22 AM), and there was no documentation regarding why the second dose of Keppra was not administered.

Further review of Patient #2's MAR revealed Aspirin, Tenormin (treats high blood pressure and chest pain), nor Microzide (treats high blood pressure and fluid retention) were administered to the patient on 02/04/19 due to "held for low BP [blood pressure]." However, there was no documented evidence that staff obtained the patient's blood pressure on 02/04/19.

2. Review of Patient #5's medical record revealed the patient presented to the ED on 02/03/19 at 12:33 AM with "Psychiatric Symptoms."

Further review of Patient #5's medical record dated 02/03/19 at 1:30 AM, revealed Patient #5 was seen by the Medical Director in ED Room 17 [Evaluation Room] and was being committed on an involuntary basis. However, interview with the Executive Director of the Psychiatric Unit on 02/11/19 at 12:40 PM revealed there was no inpatient bed available for the patient.

Review of Patient #5's physician orders revealed on 02/03/19 at 12:30 PM, the patient's physician prescribed Prolixin daily (treats schizophrenia), and at 4:30 PM, the physician ordered Depakote (treats seizures and bipolar disorders) twice daily for Patient #5. However, a review of Patient #5's Medication Administration Record (MAR) revealed no documented evidence that staff administered Depakote on 02/03/19 (the reason was not documented) or on 02/04/19 due to "med [medication] not available." Further review revealed on 02/03/19 Prolixin was not administered due to "med not available."

3. Review of Patient #1's medical record revealed the patient presented to the ED via Emergency Medical Services (EMS) on 02/05/19 at 4:26 PM from a nursing facility due to an involuntary petition for a behavioral health evaluation.

Review of Patient #1's Nursing Home to Hospital Transfer Form dated 02/05/19, completed by the nursing facility revealed the patient utilized a rolling walker, was at risk for falls, and was transferred to the facility due to behaviors. The Nursing Home Transfer Form revealed Patient #1's medications included Ativan three times a day (treats anxiety), Haldol four times per day (treats schizophrenia), Paliperidone one time daily (treats schizophrenia), Norco twice daily (treats Chronic Pain), Keppra (treats seizures), and Celexa once daily (treats depression). Further review revealed the patient required a pureed diet with large portions.

Continued review of Patient #1's ED notes dated 02/05/19 at 10:00 PM revealed the Qualified Mental Health Professional (QMHP) evaluated the patient and the patient did not meet the criteria for an admission to the behavioral health unit. However, an ambulance was not available to transport the patient back to the nursing facility until "sometime" after 8:00 PM on 02/06/19. According to the ED record, Patient #1 was not discharged until 02/06/19 at 3:30 PM.

Further review of Patient #1's ED Medical Record revealed on 02/05/19 during the patient's initial assessment, the facility documented the medications that the patient routinely took at the nursing facility; however, there was no documented evidence that the patient's medications were ordered/administered during the patient's approximately twenty-four hour stay in the ED.

Further review of Patient #1's ED record revealed no documented evidence that a meal/food was ordered or provided to the patient during the approximately twenty-four hours that the patient was in the ED Evaluation Room.

Interview with the Administrator of the nursing facility on 02/12/19 at 10:15 AM revealed when Patient #1 arrived from the ED on 02/06/19, the patient told her that he/she "had not ate anything" since the patient left the nursing facility. The Administrator stated she obtained a meal for the patient and the patient ate "like someone who was very hungry." The Nursing Facility Administrator stated she reported her concerns with the patient's care to the hospital's House Supervisor on 02/06/19.

Interview with Registered Nurse (RN) #14 on 02/11/19 at 11:50 AM revealed she provided care for Patient #1 on 02/05/19 until 7:00 PM and on 02/06/19 from 7:00 AM until the patient was discharged at approximately 3:30 PM. RN #14 stated she thought she asked a security guard to bring Patient #1 a meal tray on the evening of 02/05/19, and the patient refused to eat. The RN could not recall whether the patient ate/refused to eat on 02/06/19. RN #14 stated she was responsible for documenting when a patient ate or refused meals; however, she failed to document regarding Patient #1's food intake on 02/05/19 and on 02/06/19.

Interview with RN #15 on 02/12/19 at 3:55 PM revealed he provided care for Patient #1 until 7:00 PM on 02/05/19. He stated he remembered offering Patient #1 something to drink, but could not remember if Patient #1 received a meal tray or if he/she was offered a snack box.

Interview with RN #18 on 02/18/19 at 7:20 AM revealed she provided care for Patient #1 during the night of 02/05-06/19. RN #18 stated most of the time there was no food stocked in the ED Evaluation Room. She stated staff were required to notify the House Supervisor when a patient needed food and the House Supervisor would bring food if there was someone working in the Dietary Department. RN #18 stated between 2:00 and 3:00 AM, there was no one working in the Dietary Department to obtain food from and patients had to wait. RN #18 stated she had asked for food for patients in the past, and when she left at 7:00 AM, she had still not received the food.

Interview with the Medical Director on 02/18/19 at 5:20 PM revealed that Patient #1's medications should have been ordered and administered because the patient was in the Evaluation Room for so long. The Physician stated specifically that the patient needed Ativan and Keppra medications.

4. Observation of Patient #3 on 02/11/19 at 5:00 PM, revealed the patient was lying on the floor of the Evaluation Room on a sheet with his/her head on a pillow and there were two other male patients in the room.

Review of Patient #3's medical record revealed the patient presented to the ED on 02/10/19 at 8:00 PM, approximately twenty-one (21) hours earlier with "Psychiatric Symptoms." Review of the Triage Note dated 02/10/19 at 8:00 PM revealed the patient arrived via Law Enforcement with hallucinations, and hearing voices telling the patient to harm himself/herself. The patient reported that he/she had swallowed the hook from an earring earlier and had been seen and treated at a primary care center.

Further review of Patient #3's medical record dated 02/10/19 at 11:33 PM revealed the Quality Mental Health Professional (QMHP) had evaluated the patient and found that he/she met criteria for a psychiatric admission. However, interview with the Executive Director of the Psychiatric Unit on 02/11/19 at 12:40 PM revealed there was no inpatient bed available for the patient.

Further review of Patient #3's medical record revealed no documented evidence that a lunch meal was ordered for the patient on 02/11/19 while in the Evaluation Room. Interview with Patient #3 on 02/11/19 at 5:00 PM, revealed staff offered a breakfast meal on 02/11/19 at 7:30 AM, but he/she did not want to eat. However, Patient #3 stated staff had not offered a lunch meal on 02/11/19. The patient stated he/she "hoped" staff would offer a meal tray that evening. During the interview at 5:10 PM, RN #14 entered the Evaluation Room and told the patients that meal trays would be arriving at 5:30 PM. When RN #14 left the Evaluation Room, unsampled Patient H stated, "You need to stay in here with us. I'm sure they would feed us with you here."

Interview with RN #14 on 02/13/19 at 1:30 PM, who was working on 02/11/19, revealed she could not remember whether Patient #3 received a lunch meal tray or if the patient did not want to eat. However, she stated she offered a meal to everyone in the room.

Interview with the Dietary Manager on 02/19/19 at 3:13 PM revealed dietary staff stocked the Evaluation Room daily at 7:00 PM with six (6) "snack box meals" that contained a turkey sandwich, pasta salad, fruit, milk, and condiments. According to the Dietary Manager, she would supply extra snack boxes if they were needed; however, staff did not routinely ask for extra food. Further interview revealed she only routinely provided meals to patients if the patient had a physician's order for a meal.

Continued interview with RN #18 on 02/18/19 at 7:20 PM, revealed there was a refrigerator in the Evaluation Room; however, there was rarely any food stocked in the refrigerator. According to RN #18, when the refrigerator was stocked, ED staff often took the food for themselves or for other patients in the ED. Observation of the Evaluation Room refrigerator and pantry revealed during the interview with the RN, a physician came and left with the only bottle of Sprite that was stocked in the room. RN #18 stated ED staff often took food/drinks from the Evaluation Room.

Interview with RN #17 on 02/19/19 at 6:03 PM revealed he had worked in the ED Evaluation Room for two (2) years and worked the 7:00 PM to 7:00 AM shift. RN #17 also stated the Evaluation Room refrigerator was never stocked with enough food to feed all the patients and he had to tell patients that they had to wait for breakfast to get food.

Interview with RN #17 on 02/19/19 at 6:03 PM revealed some medications were not available in the ED Pyxis machine (electronic medication storage cabinet), but at times he did not know the medications were not available until after going to the Pyxis. He stated staff could obtain medications from the pharmacy, but stated, "Sometimes you have to wait a long time."

Interview with RN #16 on 02/14/19 at 3:20 PM also revealed staff had to obtain patients' medications from the ED Pyxis machine. However, RN #16 stated many commonly used psychotropic drugs and other non-emergent drugs were not available in the Pyxis machine. RN #16 further stated he had notified the Director of Nursing (DON) in the past that if patients were going to be in the Evaluation Room for more than twenty-four (24) hours, staff needed medications to be available. He stated he had also notified the facility's Pharmacy Department when medications were needed, but did not receive the medications.

Interview with the DON on 02/20/19 at 2:45 PM confirmed she was aware that commonly prescribed psychoactive maintenance medications were not available in the ED. She stated she had talked with the Pharmacy Department concerning stocking the Pyxis; however, she stated nurses were required to notify the House Supervisor when they did not have access to ordered medications in the ED. According to the DON, staff should call the House Supervisor if they run out of food for the Evaluation Room.

Interview with House Supervisor #3 on 02/19/19 at 7:33 PM revealed the Evaluation Room Nurse had never notified her that the Pyxis did not have the ordered medications needed for patients. However, she stated she would not have known what to do even if staff had notified her. She stated, "This has not been explained to me."

Interview with the Pharmacy Director on 02/19/19 at 5:15 PM revealed the ED had a pharmacist available ten (10) hours a day, seven (7) days a week, and a pharmacist was in the facility twenty-four hours a day, every day. The Pharmacy Director stated staff were required to obtain medications for patients from the ED Pyxis machine. She stated when a medication was not available in the Pyxis, Pharmacy could always supply the medication if they were notified.

Interview with the Emergency Department (ED) Director on 02/13/19 at 3:15 PM revealed the psychiatric nurse who worked in the Evaluation Room was responsible for the care of the patients in that room. According to the ED Director, even though the patients were considered ED patients, the staff were supervised by the Psychiatric Department.

Interview with the Executive Director of the Psychiatric Department on 02/20/19 at 3:40 PM revealed the Evaluation Room nurses were responsible for obtaining orders for meal trays for patients in the Evaluation Room. He stated prior to the state agency's investigation, he had not identified that patients were not receiving meals. Further interview revealed after the physician ordered a medication, nurses were responsible for ensuring the patients received their medications. He further stated nurses should notify the House Supervisor or could call the pharmacy themselves if the ordered medications were not available. He stated he was not aware patients were not receiving ordered medications while patients in the Evaluation Room.

Based on observation, interview, and record review, it was determined the facility failed to establish policies and procedures governing the care of patients in the Emergency Department (ED) Evaluation Room. Observation and interview revealed patients who presented to the ED (male and female) with behavioral health concerns were taken to an approximately 199 square foot room in the ED for evaluation and treatment. Interview and record review revealed patients sometimes had to wait in the room that was furnished with six (6) chairs and had no beds, for more than twenty-four (24) hours when inpatient psychiatric beds were not available or patients had no transportation available to leave the ED. The facility failed to establish a policy/procedure regarding care and treatment for patients in the Evaluation Room or for patients who had to spend an increased amount of time in the ED room; subsequently, interviews with staff and patients revealed patients had no other choice but to sleep in a chair or on the floor when they were held in the ED Evaluation Room.

The findings include:

Interview with the ED Director on 02/13/19 at 3:15 PM revealed the facility did not have a policy or procedure regarding the ED Evaluation Room, but explained that any patient who presented with behavioral health signs/symptoms was taken to the Evaluation Room for evaluation/treatment. The patient was then evaluated by the ED Physician and received a mental health evaluation while in the Evaluation Room. Continued interview with the ED Director revealed the patient remained in the Evaluation Room until the patient was admitted, transferred, or discharged, which could be an extended amount of time due to bed availability/transportation issues.

Observation of the Evaluation Room (Room 17) in the ED on 02/11/19 at 11:45 AM and 5:00 PM and on 02/14/19 at 1:25 PM revealed the room was furnished with six (6) hard rubber/vinyl chairs. On 02/14/19 at 1:25 PM, the facility Maintenance Director measured the room and determined the room was approximately 199 square feet. Further review revealed male and female patients occupied the room and shared a restroom located in the Evaluation Room. Further observation revealed there were twenty-four (24) beds available in the Emergency Department.

Review of the facility's ED log for 02/01/19 through 02/13/19 and a list of patients seen in the Evaluation Room provided by the facility revealed twelve (12) patients stayed in the ED Evaluation Room for approximately twenty-four (24) hours, even though the room was not furnished with beds.

1. Review of Patient #2's ED medical record revealed the patient presented to the ED on 02/02/19 at 8:26 PM with "Psychiatric Symptoms." Review of the physician's evaluation dated 02/02/19 at 10:35 PM revealed the patient had auditory and visual hallucinations, exhibited paranoia, and used methamphetamine. According to the note, the QMHP had also evaluated the patient and the recommendation was to place the patient under a 72-hour hold because the patient "did not have the mental capacity to be able to voluntarily commit [him/her] self."

Continued review revealed Patient #2 was not admitted to the Psychiatric Unit until 02/05/19 at 1:11 AM, approximately three days after the patient presented to the ED for treatment.

Interview with Patient #2 on 02/11/19 at 1:22 PM revealed he/she was in the Evaluation Room with twelve (12) to thirteen (13) other patients on 02/04/19. Patient #2 stated, "People were laying in the floor, sitting in the chairs, and there were people everywhere."

Review of Patient #5's medical record revealed the patient presented to the ED on 02/03/19 at 12:33 AM with "Psychiatric Symptoms." Review of the Triage Note dated 02/03/19 at 12:33 AM revealed the patient arrived via Law Enforcement with a Mental Inquest Warrant for a seventy-two (72) hour hold. Review of the Mental Inquest Warrant revealed Patient #5 told a Licensed Clinical Social Worker (LCSW) that he/she had not been taking his/her medications and was having hallucinations and delusions. Further review revealed the patient believed someone was trying to kill him/her and had been interacting with his/her hallucinations. According to the documentation, Patient #5 had been wandering in the streets and was a danger to self and others.

Further review of Patient #5's medical record dated 02/03/19 at 1:30 AM, revealed Patient #5 was seen by the Medical Director in ED Room 17 [Evaluation Room] and was being committed on an involuntary basis. However, further review of the patient's record revealed Patient #5 was not admitted to the Psychiatric Unit until 02/04/19 at 11:16 PM, approximately twenty-four (24) hours after presentation to the ED.

Review of the Facility's ED log dated 02/02/19 and 02/03/19 and a list of patients who were evaluated/treated in the Evaluation Room provided by the facility, revealed one other patient spent most of the night in the ED Evaluation Room with Patient #2 on 02/02-03/19.

Review of the Facility's ED log dated 02/03/19 and 02/04/19 and a list of patients who were evaluated/treated in the Evaluation Room provided by the facility, revealed approximately twenty-two (22) patients presented to the ED with "psychiatric symptoms" on 02/03/19 from 12:00 AM through 7:00 AM on 02/04/19. Further review revealed during the night of 02/03-04/19, approximately of four (4) patients (male and female) spent most of the night in the room, which included Patient #2 and Patient #5. Further review revealed the maximum number of patients in the room during the night was seven (7) patients.

Further review of the Facility's ED log dated 02/04/19 and 02/05/19 and a review of the facility provided list of patients revealed twenty-three patients presented to the ED and/or were held in the Evaluation Room with "psychiatric symptoms" from 12:00 AM on 02/04/19 through 7:00 AM on 02/05/19. According to the ED log for the night of 02/04-05/19, approximately ten (10) patients (male and female), spent most of the night in the approximately 199 square foot room, which included Patient #2 and Patient #5. At one time during the night, there were approximately fourteen (14) patients assigned to the Evaluation Room at one time.

2. Review of Patient #1's medical record revealed the patient presented to the ED via Emergency Medical Services (EMS) on 02/05/19 at 4:26 PM from a nursing facility due to an involuntary petition for a behavioral health evaluation.

Continued review of Patient #1's ED notes dated 02/05/19 at 10:00 PM revealed the Qualified Mental Health Professional (QMHP) evaluated the patient and the patient did not meet the criteria for an admission to the behavioral health unit. However, further review of Patient #1's ED notes revealed an ambulance was not available to transport the patient back to the nursing facility until "sometime" after 8:00 PM on 02/06/19. According to the ED record, Patient #1 was not discharged until 02/06/19 at 3:30 PM.

Continued review of the Facility's ED log dated 02/05/19 and 02/06/19 and the list of patients provided by the facility revealed approximately eleven (11) patients presented to the ED with "psychiatric symptoms" on 02/05/19 from 12:00 AM through 7:00 AM on 02/06/19 and were evaluated/treated in the Evaluation Room, or remained in the room after presentation to the ED on 02/02/19, 02/03/19, or 02/04/19. Further review revealed during the night of 02/05-06/19, approximately five (5) patients spent the night in the room, which included Patient #1, and Patient #2 who presented to the ED on 02/02/19 and was admitted on 02/05/19 at 1:11 AM.

3. Observation on 02/11/19 at 5:00 PM revealed Patient #3 was lying on a sheet on the floor with a pillow under his/her head.

Review of Patient #3's medical record revealed the patient presented to the ED on 02/10/19 at 8:00 PM, approximately twenty-one (21) hours before with "Psychiatric Symptoms." Review of the Triage Note dated 02/10/19 at 8:00 PM revealed the patient arrived via Law Enforcement with hallucinations, and hearing voices telling the patient to harm himself/herself. The patient reported that he/she had swallowed the hook from an earring earlier and had been seen and treated at a primary care center.

Further review of Patient #3's medical record dated 02/10/19 at 11:33 PM revealed the Quality Mental Health Professional (QMHP) evaluated the patient and found that he/she met criteria for a psychiatric admission. However, Patient #3 was not admitted until 02/11/19 at 8:09 PM, twenty-four hours after presentation to the facility's ED and nine hours after the QMHP documented that the patient met criteria for admission.

Continued review of the Facility's ED log dated 02/10/19 and 02/11/19 and a list of patients who were evaluated/treated in the Evaluation Room provided by the facility revealed approximately twelve (12) patients presented to the ED with "psychiatric symptoms" on 02/10/19 from 12:00 AM through 7:00 AM on 02/11/19 and were evaluated/treated in the Evaluation Room. Further review revealed during the night of 02/10-11/19, approximately three (3) patients spent the night in the room, which included Patient #3.

Interview with the Executive Director of the Psychiatric Unit on 02/11/19 at 12:40 PM and on 02/20/19 at 3:40 PM revealed the Psychiatric Unit was at full capacity and beds were not available for new admissions from 01/30/19 until 02/05/19 due to a flood that affected twenty-five (25) patient beds. Further interview revealed there were other times when beds were not available as well (02/10-11/19). He stated patients who required an admission had to stay in the ED Evaluation Room until a bed became available. Further review revealed even though the Director stated he was aware there were no beds in the Evaluation Room and patients had to spend the night, he stated he was not aware that staff were giving the patients sheets, pillows, or blankets to sleep on the floor. Further interview revealed he recalled a nurse asking if a patient could sleep on a bed in the ED; however, he was not aware there were any beds available.

Interview with the Director of Nursing on 02/20/19 at 2:45 PM revealed she was not aware that patients had to sleep on the floor/in chairs while in the ED.

Interview with the Emergency Department (ED) Director on 02/13/19 at 3:15 PM revealed he was also aware patients had to stay in the Evaluation Room for an extended period at times, even though there were no beds in the room and the room was over capacity at times. The Director stated the patients were kept in the Evaluation Room and not allowed in the ED for safety reasons. He stated the Evaluation Room was furnished with heavy chairs that could not be picked up/thrown and there were no items in the room that the patients could use to harm themselves/others. Further interview with the ED Director revealed the facility did not have a policy/procedure regarding the care of patients in instances when there were no beds available on the Psychiatric Unit or when residents did not have transportation available to leave the ED.