HospitalInspections.org

Based on document review and interview, the hospital failed to maintain a list of all contracted services which included the scope and nature of the services provided.

Findings:

Review of the contract binder provided by the hospital revealed there was no list of contracted services.

In an interview on 4/20/17 at 10:30 a.m. with S1ADM, she verified there was no list of contracted services.

Based on record review, observation and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R3, #R4, #R5) of 6 patients reviewed (See findings in tag A-0144).

2) Failing to ensure a patient with oxygen tubing that had been admitted with suicidal ideations was observed in constant line of sight for 1 (#3) of 2 (#1, #3) current patients with oxygen tubing (See findings tag A-0144).

3) Failing to ensure a suicide/homicide risk assessment had been completed by the RN before an observation level had been ordered by the physician who had not yet assessed the patient for 3 (#1, #3, #4) of 3 patients reviewed for risk assessments and ordered observation levels (See findings tag A-0144).

4) Assigning all newly admitted psychiatric patients every 15 minute monitoring prior to a risk assessment being completed including patients who's condition warranted a higher level of observation for the safety of the patient for 3 (#1,#3,#15) of 11 (#1-#10, #15) current patients reviewed (See findings tag A-0144).

5) Failing to ensure Patients rooms did not have safety risks for 11 of 11 patient rooms (See findings tag A-0144).






30984

Based on record review, observation, and interview the hospital failed to ensure each patient had a right to privacy that included the right to dignity while in the hospital as evidenced by observations of:
1) advising a patient (Patient #8) in the dining room to wait until another staff member was available to assist him to the toilet and telling him it was ok to toilet on himself because the staff could change him if he did, and;
2) staff's discussion of a patient's medications and safety plan in a small public foyer/waiting area, containing open access via public elevators, with the patient (#2) and her family member, while other persons not related to the patient were present in the foyer/waiting area.

Findings:

Review of a policy and procedure titled, "Rights and Responsibilities of the Individual; Informing Patients of Rights" (#RI-11, approved for use by the Governing Body on February 06, 2017), provided by S2COO as current, revealed, patient rights included, in part, "the right to be treated with consideration, respect and recognition of their individuality, including the need for privacy...".

1) Advising a patient (Patient #8) in the dining room to wait until another staff member was available to assist him to the toilet and telling him it was ok to toilet on himself because the staff could change him if he did:

An observation in the dining room on 04/18/17 at 12:55 p.m., when patients were being taken to their rooms for rest after lunch, revealed S12MHT was seated at a table with a patient and Patient #8 was seated at a table alone. All other staff and patients had left the room. Patient #8 started to stand and S12MHT came and assisted him back into the chair, and told him, "Can you give me just about 2 minutes until someone else comes back and they can take you to your room?" Patient #8 responded , "If I don't use it on myself." S12MHT told the patient, "That's Ok, we can change you".

In an interview on 04/20/17 at 2:25 p.m., S12MHT verified that she had instructed Patient #8 that he had to wait until another staff member returned to the dining area to take him to the bathroom, and he could go ahead, and "make" (toilet). S12MHT confirmed she said to the patient "Its ok, if you do we can change you." She said they "usually tell them to make (toilet), and we'll clean you up if you go."

In an interview on 04/18/17 at 3:30 p.m., with S1Adm, S2COO, and S3DON, all present for the interview verified that no patient should be told to toilet on themselves.


2) Staff's discussion of a patient's medications and safety plan in a small public foyer/waiting area, containing open access via public elevators, with the patient (#2) and her family member, while other persons not related to the patient were present in the foyer/waiting area:

An observation on 04/19/17 at 4:30 p.m. revealed Patient #2 was sitting in the public foyer/waiting area in front of the elevators, with her spouse and S8SW. S8SW was speaking with the patient and her spouse regarding the patient's discharge information. Further observation revealed another male sitting in the small foyer/waiting area filling out an application form. The conversation between Patient #2, her spouse, and the social worker continued. After notification of the administrator by a surveyor, she (the administrator) entered the foyer/waiting area and advised the person filling out the application that he could not fill out the application there. She asked the social worker to move to a private area in the hospital.

In an interview on 04/19/17 at 8:15 a.m., S1Adm verified the identities of Patient # 2, her spouse, and S8SW. Both S1Adm and S2COO confirmed that the discussion/assessment of the patient should not have been done in a public, non-private area. They agreed that the area in which the interaction occurred was a public area, where anyone could walk through going to and/or from the hospital areas or arrival via elevators. S1Adm reported that the patient was leaving (discharged) and verbalized she was very anxious, so S8SW had been asked to come to assess the patient and talk with her. She acknowledged that this assessment and contact should have been in an area that provided privacy for the patient and protected her information.

In an interview on 04/20/17 at 9:55 a.m., S8SW reported she was asked to assess and speak with Patient #2 because the patient had reported being very anxious. She indicated she walked out to the foyer where S10RN was talking with the patient and her spouse. S8SW reported she spoke with the patient, and came up with and went over a safety contract with the patient. She agreed that the interaction with the patient should have been conducted in a private area.

In an interview on 04/20/17 at 2:20 p.m., S10RN reported she had spoken to Patient #2 and her family member, in the open (public) foyer/waiting room the afternoon of 04/19/17. The RN indicated she was answering questions Patient #8's spouse had about her medication, as they were leaving. She confirmed this was not a private area, and didn't think about there being anyone else around, or that they might enter the area. She indicated she wasn't used to bringing family members onto the locked unit, and just didn't consider it was not a private area. She indicated she could not remember noticing if there was anyone else present in the foyer/waiting area while she was reviewing Patient #2's medications with her and her spouse.

Based on record reviews, interviews and observations, the hospital failed to ensure each patient had the right to receive care in a safe setting as evidenced by:

1) Failing to ensure patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R1, #R2, #R3) of 6 patients reviewed for supervision as ordered out of a total of 15 sampled patients and 3 random patients.;
2) Failing to ensure a patient with oxygen tubing that had been admitted with suicidal ideations was observed in constant line of sight for 1 (#3) of 2 (#1, #3) current patients with oxygen tubing out of a total sample of 15 ;
3) Failing to ensure a suicide/homicide risk assessment had been completed by the RN before an observation level had been ordered by the physician who had not yet assessed the patient for 3 (#1, #3, #4) of 3 patients reviewed for risk assessments and ordered observation levels out of a total sample of 15;
4) Having patients at risk for danger to self and others with inconsistent and inconclusive suicide risk assessments;
5) Assigning all newly admitted psychiatric patients every 15 minute monitoring prior to a risk assessment being completed which may have indicated a higher level of observation should have been maintained for the safety of the patient for 3 (#1,#3,#15) of 11 (#1-#10, #15) current patients reviewed out of a total sample of 15; and
6) Failing to ensure patients rooms did not have safety risks for 11 of 11 patient rooms.

Findings:

1) Failing to ensure patient observations by staff were conducted as ordered by the physician.

Review of the hospital policy titled Patient Observation, Chapter: PC 36 - Provision of Care, revealed in part:
B. Category II: Continuous Supervision
3. Nursing Interventions:
a) with staff visual field at all times

Review of documentation provided by the hospital revealed the following patients were ordered to be on line of sight:
Patient #1 and Patient #3 were on line of sight due to the risks of having oxygen tubing.
Patient #4 was on line of sight for suicidal ideations.
Patient #5 was on line of sight because she was a fall risk.
Patient #8 was line of sight because of falls and aggression.

Review of the hospital documents titled Nursing Assignment Sheet dated 4/17/17 revealed the following:
S20MHTwas assigned to Patient #R2, #1 and #4. Patient #1 and Patient #4 could be observed in line of sight at night from one location in the hallway but the station would have to be abandoned to view Patient #R2. All three patients were documented as having been observed by S20MHT every 15 minutes. S20MHT also documented he observed S21MHT's 4 patients on another hallway at 11:30 p.m. and 11:45 p.m. (2 of which were line of sight patients).

S22MHT was assigned Patient #8 who was to be observed on line of sight at all times. She was also assigned 15 minute observations on Patient #12, Patient #14, and Patient #2 (on another hallway). All 4 patients were documented as having been observed by S20MHT every 15 minutes.

S21MHT was assigned Patient #3 and Patient #5 who were line of sight but not able to be seen from one location. She was also assigned Patient #R3 and Patient #11 to observe every 15 minutes. All four patients could not be seen from one location but were documented as having been observed every 15 minutes by S21MHT.

In an interview on 4/18/17 at 3:35 p.m., S3DON verified there was no possible way S20MHT, S21MHT and S22MHT could have observed their assigned patients as ordered on the night of 4/17/17.

In an interview on 4/19/17 at 9:15 a.m. with S30RN, she said she was the charge nurse on the night of 4/17/17. She verified she made the MHT's assignments. She said she reviewed the 15 minute and line of sight observation sheets from the night of 4/17/17 and it was not accurate. S30RN said they helped each other but the documentation did not reflect that.

In an interview on 4/19/17 at 9:20 a.m. with S1ADM, she said she reviewed the video tape of the hallways in the hospital from the night of 4/17/17. S1ADM verified the staff did not observe the line of sight patients at all times.


2) Failing to ensure a patient with oxygen tubing that had been admitted with suicidal ideations was observed in constant line of sight.

Review of the hospital policy titled Oxygen Therapy, Chapter PC 97-Provision of Care, said in part:
Nurse: Monitors safe use of Oxygen and sets limits as needed (line of sight observation while in use).

Review of the daily nursing flow sheet dated 4/18/17 for Patient #3 revealed she had been
assessed as having intermittent suicidal ideation.

Review of Patient #3's Initial Psychiatric Evaluation dated 4/13/17 at 5:17 p.m. revealed in part:
Pt states she is here because she was very depressed and could not stop crying. Affect depressed mood is depressed. She reported daily crying. Feels hopeless and worthless. She reports that she had been hearing voices. Says the voices tell her they want to hurt her but not kill her.

In an observation on 4/18/17 at 2:45 p.m., Patient #3 was in her room in bed with no attendant present. Patient #3 had oxygen tubing and a concentrator in the room.

Review of Patient #3's Close observation form revealed she had gone into her room at 1:00 p.m. and had only been observed every 15 minutes until 2:45 p.m. (1 hour and 45 minutes).

In an interview on 4/18 /17 at 2:50 p.m. with S11LPN, she said she had been observing Patient #3 every 15 minutes. S11LPN said she was not aware Patient #3 needed to be observed in line of sight.

In an interview on 4/18/17 at 2:52 p.m. with S3DON, he said a patient on a nasal cannula in their bedroom should have been a line of sight at all times.

In an interview on 4/18/17 at 3:27 p.m. with S1ADM, she verified patients with oxygen tubing should not be in their rooms unobserved.


3) Failing to ensure a suicide/homicide risk assessment had been completed by the RN before an observation level had been ordered by the physician who had not yet assessed the patient.

Patient #1
Review of the medical record for Patient #1 revealed diagnoses which included Suicidal Ideations and Major depressive disorder recurrent. Further review revealed he had been threatening to kill his wife and said he would kill himself. Review of Patient #1's suicide risk assessment completed by the nursing staff on 4/17/17 at 6:36 p.m. revealed she had scored Patient #1 a moderate risk which should have placed the patient in line of sight. Further review revealed the nurse had spoken with the physician at 5:17 p.m., 1 hour and 19 minutes before the assessment, and the physician had ordered the patient to be on 15 minute observations. The physician had ordered the observation level without assessing the patient and before the RN had completed a suicide risk assessment. The observation level was not increased after the RN risk assessment and there was no documentation that the physician was notified of the results.

Patient #2
Review of Patient #2's medical record revealed she had been admitted at 3/29/17 at 1:05 p.m. with diagnoses which included Major depressive disorder with Schizoaffective disorder. Further review revealed Patient #2's risk assessment for being a danger to herself or others had not been completed until 3:28 p.m. Patient #2 was scored as moderate risk to others and a high risk to herself which would warrant 1:1 supervision. Patient #2 was on 15 minute observations until 4/06/17.

Review of the physician's orders revealed she had been ordered to be on 15 minute observations by the physician at 11:47 a.m. (1 hour and 17 minutes before the patient arrived to the hospital). Neither the physician nor the nurse had assessed the patient when the observation orders had been obtained.

Patient #4
Review of Patient #4's medical record revealed he had been admitted on 4/17/17 at 7:40 p.m. with diagnoses which included Suicidal ideations and Major Depressive Disorder. Further review revealed Patient #4's risk assessment had not been completed by the RN until 8:53 p.m. Review of Patient #4's physician's order for observation level revealed it had been ordered at 7:44 p.m. (4 minutes after arrival and 1 hour and 13 minutes before the risk assessment had been completed). There was no documentation of the physician or the RN having assessed Patient #4 before his observation level had been ordered.

In an interview on 4/18/17 at 1:48 p.m., S3DON said the nurses should have completed the admission risk assessment before calling the physician for observation level orders. S3DON said the LPN calls the physician and gives a run down to the physician of why the patient was there. He said the purpose of the suicide risk assessment was to determine the risk of the patient harming themselves or others. He said based on the RN assessment, the nurse should have called the physician back to let him know what the patient scored.


4) Having patients at risk for danger to self and others with inconsistent and inconclusive suicide risk assessments.

Review of the document titled Risk Assessment revealed it was a tool the nursing staff and social workers used to determine if a patient was no risk, a low risk, a moderate risk, or a high risk to themselves or others. Further review revealed a list of risk factors was rated from no risk to high risk based on the patient's history and current status. Once the form was completed, the staff completing the form would subjectively determine at what level of observation the patient needed to be monitored for safety. The form had no number system or guidance as to how the observation level would be determined by the risk factors selected.

In an interview on 4/19/17 at 11:10 a.m. with S5Psychiatrist, he said the risk assessment tool used by the nurses needed to be changed because it was not a scoring system to determine the level of observation needed which was the standard.

In an interview on 4/20/17 at 10:45 a.m. with S2COO, she verified the corporate level of the hospital knew the risk assessment tool needed to be changed to be more objective because of a deficiency at one of their other facilities. S2COO said the reason the new tool was not implemented at the hospital was because the management had not perfected the new tool yet.


5) Assigning all newly admitted psychiatric patients every 15 minute monitoring prior to a risk assessment being completed which may have indicated a higher level of observation should have been maintained for the safety of the patient.

Patient #1
Review of Patient #1's medical record revealed an admission date of 04/17/17 with an admission diagnosis of Bipolar Disorder with Suicidal ideations. Review of Patient #1's Close Observation forms revealed the patient was on Observation Level III-Close Observation -Q (every) 15 minute checks with assaultive, suicide, fall and swallowing precautions. Further review revealed the initial entry on Patient #1's observation forms was at 5:00 p.m. on 04/17/17. Review of Patient #1's medical record revealed the Initial Risk Assessment was dated 04/17/17 at 7:13 p.m. (2 hours and 13 minutes after the initial entry on Patient #1's Close Observation form).

Patient #3
Review of Patient #3's medical record revealed an admission date of 04/12/17 with admission diagnoses including Alzheimer's Dementia, Major Depressive Disorder with Psychosis, and Suicidal Ideations. Patient #3 was also receiving continuous oxygen via nasal cannula (a Hospital supervision policy criteria that indicated initiation of line of sight observation at all times). Review of Patient #3's Close Observation forms revealed the patient was on Observation Level III-Close Observation -Q (every) 15 minute checks with fall and elopement precautions. Further review revealed the initial entry on Patient #3's observation forms was at 7:00 p.m. on 04/12/17. Review of Patient #3's medical record revealed the Initial Risk Assessment was dated 04/13/17 at 3:04 a.m. (8 hours and 4 minutes after the initial entry on Patient #3's Close Observation form).


Patient #15
Review of Patient #15's medical record revealed an admission date of 04/14/17 with admission diagnoses including Major Depressive Disorder and Anxiety Disorder. Review of Patient #15's Close Observation forms revealed the patient was on Observation Level III-Close Observation -Q (every) 15 minute checks with fall precautions. Further review revealed the initial entry on Patient #15's observation forms was at 1:15 p.m. on 04/14/17. Review of Patient #15's medical record revealed the Initial Risk Assessment was dated 04/14/17 at 2:04 p.m. (49 minutes after the initial entry on Patient #15's Close Observation form).

In an interview on 4/19/17 at 2:40 p.m. with S2COO, she verified the nurses should have kept new admissions on line of sight for safety until a Risk Assessment had been completed by the RN and the appropriate observation level was determined to be every 15 minutes, direct line of sight or 1:1 supervision.


6) Failing to ensure Patients rooms did not have safety risks for 11 of 11 patient rooms.

A tour was made of the patients' rooms with S3DON on 4/18/17 beginning at 9:45 a.m. There were a total of 11 double occupancy rooms. The following safety risks were identified:
a) 18 beds with metal frames and supports which presented a ligature risk.
b) Vertical blinds on the windows which were plastic and could be broken and have sharp edges. The rod at the top of the window holding the vertical blinds in place contained a space above it large enough to wrap a sheet around the top.
c) The majority of the patient rooms shared a bathroom that contained a sink with a protruding faucet that posed a ligature risk.
d) Patient rooms # 113, 115, 123, 125, 137 and 139 had sinks with protruding faucets.

S3DON verified these findings during the tour on 4/18/17 beginning at 9:45 a.m.


30984

Based on record review and interview, the hospital failed to ensure the use of restraints or seclusion was in accordance with a written modification to the patient's plan of care for 1 (#13) of 1 sampled patients reviewed for the use of restraints out of a total of 15 sampled patients.

Findings:

Review of the medical record for Patient #13 revealed she had been admitted to the hospital on 03/07/17 at 11:40 p.m. with diagnoses including Alzheimer's Disease and Bipolar Disorder mixed, severe without psychotic features. Further review revealed she was placed into 4 point restraints on 03/08/17 at 9:25 a.m. for aggressive behavior. Patient #13 was documented as having been removed from the restraints at 10:00 a.m.

Review of Patient #13's plan of care revealed there had been no modification to the plan of care to include the use of restraints on 03/08/17.

In an interview on 04/19/17 at 2:30 p.m. with S3DON, he verified Patient #13's plan of care had not been updated to include the use of restraints.

Based on record reviews and interview, the hospital failed to ensure that the data collected for QAPI was used to identify opportunities for improvement and changes that will lead to improvement. This deficient practice is evidenced by failing to have identified opportunities for improvement associated with the patients' admission risk assessment.

Findings:

A survey was conducted by the Health Standards Section of the Louisiana Department of Health at the hospital from 4/18/17 through 4/20/17. Problems were identified with the timing of the risk assessment tool in relation to obtaining observation orders, maintaining a safe observation level before the risk assessment tool could be completed, and the subjective assessment provided by the tool.

Review of the facility's QAPI data revealed the above mentioned problems had not been identified by the hospital.

In an interview on 4/20/17 at 10:42 a.m. with S3DON, he said until the survey team pointed it out to him, he was not aware that the risk assessment tool needed to be revised and was a problem.

In an interview on 4/20/17 at 10:45 a.m. with S2COO, she verified the corporate level of the hospital knew the risk assessment tool needed to be changed to be more objective because of a deficiency at one of their other facilities. S2COO said the reason the new tool was not implemented at the hospital was because they had not perfected the new tool yet.

Based on record review and interview, the hospital's governing body failed to ensure that the program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by the hospital's failure to include all contracted services in the hospital's QAPI program.

Findings:

Review of the hospital's contracts revealed contracts for biohazardous waste, linen services, physical therapy services and occupational therapy services.

Review of the QAPI data provided by the hospital revealed no indicators for the contracted services for biohazardous waste, linen services, physical therapy services or occupational therapy services.

In an interview on 4/20/17 at 10:50 a.m. with S2COO, she verified the above mentioned contracted services were not included in the QAPI program.

Based on record reviews, interviews and observations, the hospital failed to meet the requirements of the Condition of Participation for Nursing services as evidenced by:

1) Failing to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by failing to ensure admission orders were not written by a licensed practical nurse instead of a licensed independent practitioner privileged to write orders for 1 (#2) of 15 patients sampled (see findings tag A-0395).


2) Failing to ensure a RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidenced by having 3 MHTs who were assigned the observation of patients on direct line of sight to also be assigned the observation of other patients in separate rooms or on a different hall of the hospital on 1 of 1 days sampled (See findings tag A-0397).




30984

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by failing to ensure admission orders were not written by a licensed practical nurse instead of a licensed independent practitioner privileged to write orders for 1 (#2) of 15 patients sampled.

Findings:

Review of the hospital policy titled Care, Treatment and Services revealed in part:
Services are only provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital's medical staff to order the services in accordance with hospital policies and procedures and State laws.

Review of Patient #2's medical record revealed she had been admitted 3/29/17 at 1:05 p.m. with diagnoses which included Major depressive disorder with Schizoaffective disorder. Further review revealed the admission orders had been written as a telephone order by S15LPN from S5Psychiatrist.

In an interview on 4/19/17 at 10:27 with S15LPN, she said the RN did the assessment on the patients and the LPN entered admission orders and called the physician. She said when an admission arrived at the hospital the LPN looked at the order set the patient came with from the transferring facility. S15LPN said she then called S5Psychiatrist to go over the patient's medications and he ordered them or changed some of them. S15LPN said she put observation levels in the computer as every 15 minutes unless the RN feels they need a higher level of observation then they would ask the physician for a higher observation level. She said if the patient was a known diabetic she placed them on a diabetic diet but it was discussed with the physician. She said Patient #2 was ordered to be an every 15 minutes observation before an assessment was done by the nurse and they would change it if needed. S15LPN said she did not discuss Patient #2's observation level with S5Psychiatrist. She said if the patients were on any blood pressure medications they were selected to be on a cardiac diet by her or if they were on blood glucose medications they were ordered a diabetic diet by her. She said she entered the patient's allergies and diagnosis based off of the sending facilities information. She said she usually only went over the medications with the psychiatrist unless she may have other questions. S15LPN verified she would choose most of the admission orders without discussing them with the physician. She also verified she would sign off on all of the orders as telephone orders from S5Psychiatrist.

In an interview on 4/19/17 at 10:50 a.m. with S3DON, he verified the nurses were selecting options on the order screen for various orders and not obtaining them from the physician. S3DON also verified the nurses were documenting that the orders were telephone orders by the physician. S3DON said they did not have standing orders and protocols for all of the orders the nurses were selecting. When asked, S3DON verified it was not within the scope of practice for a nurse to be writing admission orders without receiving them from the physician.

In an interview on 4/19/17 at 11:10 a.m. with S5Psychiatrist, he said he went over the medications on new admissions with the nurse and sometimes other things. S5Psychiatrist verified the nurse's should not have been ordering for the patients and signing that it was a telephone order from him.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a comprehensive nursing care plan/treatment plan, inclusive of medical and psychological diagnoses, for 4 (#3, #5, #9, #10) of 10 patients reviewed for the nursing care plan from a total of 15 sampled patients.

Findings:

Review of a hospital policy and procedure titled, "Provision of Care, Treatment, and Services: Plan of Care" (PC74, last revised 02/02/17), provided by S7PI as current, revealed in part, every patient would have an individualized comprehensive plan of care. Further review revealed the objectives included, in part they (the patient's care plan) would be sufficiently specific to assess the progress of the individual served, were in terms that provided indices of progress, goals and objectives would be reevaluated and, as necessary, revised based on changes in the patient's condition, problems, needs, and responses to care, treatment, and services. Care, treatment or services for each patient would be based on the plan for care, treatment or services. Review of the section titled "Procedure" indicated the patient's needs would be identified from the information contained on the initial intake form and the initial nursing assessment. Care planning would include the development of treatment goals with specific objectives related to identified goals. Care, treatment and services would be planned, which included interventions, services and treatments necessary to assist the patient in meeting the identified care plan goals. These would include the frequency of care, treatment and services.

Review of a hospital policy and procedure titled, "Provision of Care, Treatment and Services: Plan of Care-Protocol for the use of Multidisciplinary Format" (#PC81) provided by S7PI as current included, in part, the Initial Plan of Care/Nursing Standards of Care and Problem-specific plan of care. Further review revealed Phase 1 (Plan of Care Development: Data Collection and Assessment) include Nursing would complete an Admission assessment within 8 hours of admission. The screens for Potential for Self-Harm, Violence, AWOL, Fall, and Detox stages must be completed as soon as possible after admission to the unit. These plans would guide provision of care until the first multidisciplinary plan of care session.


Patient #3
Review of Patient #3's medical record revealed an admission date of 04/12/17 with admission diagnoses including Alzheimer's Dementia and Major Depressive Disorder with Psychosis. Additional review revealed Patient #3 was receiving continuous oxygen via nasal cannula due to a diagnosis of COPD (Chronic Obstructive Pulmonary Disease). Further review revealed the patient also had a diagnosis of Diabetes Mellitus Type II and had an indwelling Foley Urinary catheter due to urinary retention. Review of Patient #3's treatment plan revealed Diabetes Mellitus Type II, continuous oxygen via nasal cannula for COPD, and the indwelling Foley urinary catheter for urinary retention were not addressed as problems on the plan of care.

In an interview on 04/19/17 at 10:40 a.m. with S6SW, she confirmed Diabetes Mellitus Type II, continuous oxygen via nasal cannula, and the indwelling Foley urinary catheter were not addressed as problems on the plan of care.


Patient #5
Review of Patient #5's medical record revealed an admission date of 04/10/17 with admission diagnoses including Alzheimer's disease with late onset, Dementia in other diseases with behavioral disturbance, Delirium due to know physiological condition, Hearing loss, Hypertension, Acute upper Respiratory Infection, osteoarthritis, Disorder of kidney and ureter-unspecified, Violent Behavior, Weakness, Hyperglycemia. Further review of a nursing admission assessment revealed she was incontinent, and had a history of UTIs. The nursing assessment documented the patient had a recent fall with injuries to her face, and was a high risk for falls. Review of physician orders revealed, in part she was on every 15 minute observation status, capillary blood glucose checks twice a day (started 04/18), Ensure Dietary Supplement 3 times a day, Triple Antibiotic Ointment to right forearm and Left and Right lower legs, then cover with bandage, and clean wound with wound cleanser daily, and a cardiac diet. Further review of the orders revealed the patient was ordered to have a cardiac diet, and precautions for Aggression, Falls, and AWOL (elopement). Review of the care plan for Patient #5 revealed no identified problem(s) for high fall risk, hyperglycemia, wounds, or nutritional problems.

In an interview 04/19/17 at 2:25 p.m. S7PI, on review of the medical record, verified care plans did not include the patient's medical diagnoses of hyperglycemia, special diet, wound care/skin integrity, urinary incontinence, or history of falls/fall precautions.

Patient #9
Review of Patient #9's medical record revealed an admission date of 04/12/17 with admission diagnoses including Major Depressive Disorder and Paranoid Schizophrenia. Additional review revealed Patient #9 also had a diagnosis of Diabetes Mellitus Type II. Review of Patient #9's current treatment plan revealed Diabetes Mellitus Type II had not been addressed as an identified problem on the plan of care.

In an interview on 04/19/17 at 2:39 p.m. with S6SW, she confirmed Diabetes Mellitus Type II had not been addressed as an identified problem on Patient #9's care plan. S6SW agreed Diabetes Mellitus Type II should have been addressed on the plan of care.

Patient #10
Review of Patient #10's medical record revealed an admission date of 04/10/17 with admission diagnoses including Schizoaffective Disorder-Bipolar type and Vascular Dementia. Additional review revealed Patient #10 also had a diagnosis of Diabetes Mellitus Type II. Review of Patient #10's current treatment plan revealed Diabetes Mellitus Type II had not been addressed as an identified problem on the plan of care.

In an interview on 04/19/17 at 2:47 p.m. with S6SW, she confirmed Diabetes Mellitus Type II had not been addressed as an identified problem on Patient #10's care plan.




30420

Based on record reviews and interview, the hospital failed to ensure a RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidenced by having 3 MHTs who were assigned the observation of patients on direct line of sight to also be assigned the observation of other patients in separate rooms or on a different hall of the hospital on 1 of 1 days sampled.

Findings:

Review of the hospital policy titled Patient Observation, Chapter: PC 36 - Provision of Care, revealed in part:
B. Category II: Continuous Supervision
3. Nursing Interventions:
a) with staff visual field at all times

Review of documentation provided by the hospital revealed the following patients were ordered to be on line of sight:
Patient #1 and Patient #3 were on line of sight due to the risks of having oxygen tubing.
Patient #4 was on line of sight for suicidal ideations.
Patient #5 was on line of sight because she was a fall risk.
Patient #8 was line of sight because of falls and aggression.

Review of the hospital documents titled Nursing Assignment Sheet dated 4/17/17 revealed the following:
S20MHT was assigned to Patient #R2, #1 and #4. Patient #1 and Patient #4 could be observed in line of sight at night from one location in the hallway but the station would have to be abandoned to view Patient #R2. All three patients were documented as having been observed by S20MHT every 15 minutes. S20MHT also documented he observed S21MHT's 4 patients on another hallway at 11:30 p.m. and 11:45 p.m. (2 of which were line of sight patients).

S22MHT was assigned Patient #8 who was to be observed on line of sight at all times. She was also assigned 15 minute observations on Patient #12, Patient #14, and Patient #2 (on another hallway). All 4 patients were documented as having been observed by S20MHT every 15 minutes.

S21MHT was assigned Patient #3 and Patient #5 who were line of sight but not able to be seen from one location. She was also assigned Patient #R3 and Patient #11 to observe every 15 minutes. All four patients could not be seen from one location but were documented as having been observed every 15 minutes by S21MHT.

In an interview on 4/18/17 at 3:35 p.m. S3DON verified there was no possible way S20MHT, S21MHT and S22MHT could have observed their assigned patients as ordered on the night of 4/17/17.

In an interview on 4/19/17 at 9:15 a.m. with S30RN, she said she was the charge nurse on the night of 4/17/17. She verified she made the MHT's assignments. She said she reviewed the 15 minute and line of sight observation sheets from the night of 4/17/17 and it was not accurate. S30RN said they helped each other but the documentation did not reflect that.

In an interview on 4/19/17 at 9:20 a.m. with S1Adm, she said she reviewed the video tape of the hallways in the hospital from the night of 4/17/17. She verified the staff did not observe the line of sight patients at all times.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care and failed to provide notification to the ordering practitioner of the medication errors. This deficient practice was evidenced by nursing staff failing to administer ordered medications for 2 (#1, #2) of 10 patients reviewed for medication administration of a total sample of 15.

Findings:

Patient #1
Review of Patient #1's medical record revealed Doxepin HCL Capsule 75mg at bedtime was ordered on 4/17/17 at 6:51 p.m. Further review revealed the dose was not given on 4/17/17. A note documented on the MAR indicated the medication was not available. There was no documentation that the physician had been notified.

Patient #2
Review of Patient #2's medical record revealed an order dated 3/29/17 for Prazosin HCl capsule 5 mg at hour of sleep. Further review of the MAR revealed Patient #2 did not receive her Prazosin HCl capsule 5 mg at 9:00 p.m. on 3/29/17 as ordered. A note documented on the MAR indicated the medication was not available. There was no documentation that the physician had been notified.

In an interview on 4/18/17 at 2:32 p.m. with S3DON, he said if a medication is ordered it can be sent to a local pharmacy or the pharmacy can make a special delivery. He said not administering a medication without a physician's order was a medication error.

Based on observation, record reviews, and interviews, the hospital failed to ensure patients' medical records were accurately written and completed as evidenced by failure to have patient observation forms completely documented for precaution type and observation level for 3 (#3,#9,#10) of 10 (#1- #10) current patients reviewed for the nursing care plan from a total sample of 15 patients.

Findings:

Patient #3
Review of Patient #3's medical record revealed an admission date of 04/12/17 with admission diagnoses of Major Depressive Disorder severe with psychosis, delusion and paranoia.

Review of Patient #3's admission orders, dated 04/12/17, revealed the patient was placed on observation Level III-Close observation -Q (every) 15 minute checks with fall and elopement precautions (verified by S6SW who was navigating Patient #3's electronic medical record). Additional review revealed no documented evidence of discontinuation of the elopement precautions as of 04/19/17.

Review of Patient #3's Close Observation forms dated 04/12/14, 04/13/17, 04/15/17- 04/18/17 revealed elopement precautions had not been chosen as an ordered precaution for Patient #3. Additional review of the forms revealed the precaution type and observation level was left blank on 4/14/17.

Patient #9
Review of Patient #9's medical record revealed an admission date of 04/12/17 with admission diagnoses including Major Depressive Disorder and Paranoid Schizophrenia.

Review of Patient #9's admission orders, dated 04/12/17, revealed the patient was placed on observation Level III-Close observation -Q (every) 15 minute checks with fall and elopement precautions (verified by S6SW who was navigating Patient #9's electronic medical record). Additional review revealed no documented evidence of discontinuation of the elopement precautions as of 04/19/17.

Review of Patient #9's Close Observation forms dated 04/12/17, 04/13/17, 04/15/17 and 04/17/17 revealed elopement precautions had not been chosen as an ordered precaution for Patient #9. Additional review of the forms revealed the precaution type and observation level was left blank on 04/14/17 and 04/16/17.

Patient #10
Review of Patient #10's medical record revealed an admission date of 04/10/17 with admission diagnoses including Schizoaffective Disorder-Bipolar type and Vascular Dementia.

Review of Patient #10's admission orders, dated 04/10/17, revealed the patient was placed on observation Level III-Close observation -Q (every) 15 minute checks with bleeding, assaultive (violent/aggressive), and fall precautions (verified by S6SW who was navigating Patient #10's electronic medical record). Additional review revealed no documented evidence of discontinuation of the bleeding or assaultive precautions as of 04/19/17.

Review of Patient #10's Close Observation form dated 04/11/17 revealed precaution type was left blank. Further review of the observation forms revealed the following: 04/12/17: bleeding precaution type was not documented and both Level III Close Observation- Q 15 and Level II- Constant Observation were checked; 04/13/17: both assaultive and bleeding precautions were left blank/not addressed ; 04/14/17 and 04/16/17 both Observation Level and Precaution type were left blank; 04/15/17 and 04/17/17: both assaultive and bleeding precautions were left blank/not addressed.

The above referenced findings for Patients #3, #9, and #10 were verified by S6SW on 04/19/17 at 3:30 p.m. S6SW confirmed the ordered precaution types and observation levels should have been documented on the observation forms by staff completing the forms.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiology Services as evidenced by the hospital's failure to :
1) ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by the Director of Radiology (S18MD), appointed by the Governing Body, was not a radiologist, and;
2) ensure all radiological interpretations were made by radiologists who were credentialed and privileged members of the Medical Staff. This deficient practice was evidenced by no documented evidence of radiologists, who interpreted x-rays performed on hospital patients, having been granted privileges. Hospital radiological exams were interpreted by 7 radiologists (S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, and S29MD) from Company A, that did not have approved privileges in the hospital (see A-0546).

Based on record review and interview, the hospital failed to:
1) ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by the Director of Radiology (S18MD), appointed by the Governing Body, was not a radiologist, and;

2) ensure all radiological interpretations were made by radiologists who were credentialed and privileged members of the Medical Staff. This deficient practice was evidenced by no documented evidence of radiologists, who interpreted x-rays performed on hospital patients, having been granted privileges. Hospital radiological exams were interpreted by 7 radiologists (S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, and S29MD) from Company A, that did not have approved privileges in the hospital.
Findings:

1) failure to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by the Director of Radiology (S18MD), appointed by the Governing Body, was not a radiologist:

Review of the credentialing file for S18MD revealed S18MD was appointed to the medical staff as active staff for the period of 05/31/15 to 05/30/17. Review of the CV and application for appointment for S18MD revealed the physician was a family practice physician. There was no documented evidence that the physician was also a radiologist. Review of the Delineation of Clinical Privileges for S18MD revealed, "Director of Radiology" was listed. The privileges were signed by S18MD and S5Psychiatrist on 05/15/15.

In an interview on 04/20/17 at 2:40 p.m., S1Adm confirmed S18MD was the hospital's Director of Radiology. S1Adm also confirmed S18MD was not a radiologist, but was a family practice physician. S1Adm confirmed the hospital did not have a radiologist appointed by the governing body as the Director of Radiology.

2) failure to ensure all radiological interpretations were made by radiologists who were credentialed and privileged members of the Medical Staff:

A review of a current contract between the hospital and Company A revealed the company would perform radiology exams for patients of the hospital, and all diagnostic exams would be interpreted by a licensed Radiologist.

Review of a Radiology binder, provided by S2COO revealed credentialing documents for S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, and S29MD. Further review revealed a Medical Executive Committee and Board of Trustees Approval Form for each radiologist that had the following checked: Medical Privileges approved, and Appointment Recommended, and was signed by the Chairman of the Executive Committee. Further review of each file revealed no requested or approved privileges.

In an interview 04/19/17 at 3:55 p.m. S1Adm and S2COO confirmed that the reading radiologists of Company A, although approved to the Medical Staff, did not have approved privileges. S2COO reported she thought they didn't have to be privileged because they didn't provided services onsite, but agreed they were providing services (of radiology interpretation) to hospital patients.


30420

Based on record review and staff interview, the hospital failed to ensure the Utilization Committee had two or more practitioners who were not involved in the patient's care to carry out the Utilization Review (UR) functions.
Findings:

Review of the hospital's Medical and Professional Staff Organization Bylaws, provided by S2COO as current, revealed in part the following: Section 6: Utilization Review Function. The responsibilities, duties, and authority of the UR function shall be to comply with all requirements of the utilization review plan approved by the Medical Staff and Board....The Utilization Review Function shall be a standing agenda item for the COW.

Review of the Utilization Management Plan, provided by S1Adm as the hospital's current UR plan revealed in part the following: The Committee of the Whole is a standing committee of the medical staff and is responsible to the Medical Executive Committee (MEC).... No less than two (2) members of the Committee of the Whole shall be physicians or doctors of osteopathy....Conflict of Interest: Physicians may not participate in the review of any cases in which he/she has been or anticipates being professionally involved....Physicians having a direct or indirect financial interest in the case(s) being reviewed may not participate in the utilization management activities pertaining thereto....

Review of the UR Committee Members roster provided by S1Adm as current revealed the following physicians were the only physician members: S5Psychiatrist and S17MD. The roster also revealed the following: Physicians shall not participate in the review of cases in which he/she were professionally involved.

Review of the Committee of the Whole meeting minutes dated 12/21/16, 02/24/17, and 03/31/17 revealed S5Psychiatrist was the only physician in attendance.

Review of the UR forms for Patients #13 and #R1 revealed S5Psychiatrist participated in the review of the denials on both patients and S5Psychiatrist was the admitting/attending physician for both patients.

In an interview on 04/20/17 at 9:29 a.m., S8SW confirmed she does the hospital UR and stated she started doing UR in November, 2016. S8SW stated S5Psychiatrist and his nurse practitioner, S9APRN were involved in the UR process and confirmed he was the medical director and attending physician for all the hospital's patients. S8SW stated she was not aware of an independent reviewer involved in the UR process.

In an interview on 04/20/17 at 10:30 a.m., S1Adm confirmed the routine UR was done by S5Psychiatrist and he was reviewing his own patients. S1Adm confirmed they have a process in place for S17MD, the Out-patient Medical Director to review S5Psychiatrist's records but it was not currently being done.

Based on record review and staff interview, the Hospital failed to ensure the utilization plan was implemented as evidenced by:
1) Failing to ensure all Medicare patients were included in the UR process, and;
2) Failing to conduct UR committee meetings and include all UR committee members in the meetings.

Findings:

1) Failing to ensure all Medicare patients were included in the UR process:

Review of the Utilization Management Plan, provided by S1Adm as the hospital's current UR plan revealed in part the following: The Utilization Management Plan strives for appropriate allocation of the hospital's resources by provision of quality patient care in the most cost effective manner. It provides for timely review of the medical necessity for admissions, continued stays, and services rendered. The Utilization Management Plan includes a review of services furnished by the hospital and the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. The Utilization Management Plan applies to all patients regardless of payment source....

In an interview on 04/20/17 at 9:29 a.m., S8SW stated she had been doing UR since November, 2016. S8SW stated she only reviewed insurance patients and did not review Medicare or Medicaid patients.

In an interview on 04/20/17 at 9:57 a.m., S1Adm stated S8SW was doing Medicaid reviews and she provided documentation of the reviews. S1Adm stated S8SW "was speaking from managed care aspect only." S1Adm stated she and the Director of Nursing review the Medicare and Medicaid patients but they do not document the reviews. S1Adm stated "we have fallen slack." At 12:30 p.m., S1Adm confirmed only Medicare HMO patients were part of the current UR process. S1Adm confirmed the current UR process did not include all of the hospital's patients.


2) Failing to conduct UR committee meetings and include all UR committee members in the meetings:

Review of the Utilization Management Plan, provided by S1Adm as the hospital's current UR plan revealed in part the following: The Committee of the Whole is a standing committee of the medical staff and is responsible to the Medical Executive Committee (MEC).... No less than two (2) members of the Committee of the Whole shall be physicians or doctors of osteopathy....Nonmedical staff member advisors of the Committee of the Whole are appointed annually and includes members from: Utilization Management, Performance Improvement....The Committee of the Whole meets as often as necessary at the call of its chairperson, but at least monthly.


Review of the UR Committee Members roster provided by S1Adm as current revealed the following physicians were the only physician members: S5Psychiatrist and S17MD. The roster also included the following: S8SW, UR Coordinator, S1Adm, S3DON, and S7PI.

Review of the Committee of the Whole meeting minutes dated 12/21/16, 02/24/17, and 03/31/17 revealed S5Psychiatrist was the only physician in attendance. There was no documented evidence that S8SW attended any of the meetings. Further review of the meeting minutes dated 12/21/16, 02/24/17, and 03/31/17 revealed a section for utilization review, but there was no information related to UR documented in the minutes.

In an interview on 04/20/17 at 9:29 a.m., S8SW stated she had been doing UR since November, 2016. S8SW stated she was not aware of any UR committee meetings and she had not attended any. S8SW stated she was not aware of any UR information currently being reported to QAPI and she did not attend QAPI meetings either.

In an interview on 04/20/17 at 9:57 a.m., S1Adm stated S8SW does not attend any UR meetings, but stated she probably should. S1Adm stated S8SW compiles the data and she (S1Adm) reported the data at the COW.

In an interview on 04/20/17 at 12:15 p.m., S1Adm confirmed that UR was a function of the Committee of the Whole. S1Adm reviewed the Committee of the Whole meeting minutes dated 12/21/16, 02/24/17, and 03/31/17 and confirmed S5Psychiatrist was the only physician that attended the meetings. S1Adm confirmed there was no meeting conducted in January, 2017. S1Adm confirmed there was no documentation in the minutes of the UR data or reports. S1Adm confirmed the hospital's UR plan had not been implemented.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of 482.13 (Patient Rights), 482.23 (Nursing Services), and 482.26 (Radiologic Services) as evidenced by:


1) The hospital failing to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

a) Failing to ensure patient observations by staff were conducted as ordered by the physician for 6 (#4, #5, #6, #R1, #R2, #R3) of 6 patients reviewed for supervision as ordered out of a total of 15 sampled patients and 3 random patients reviewed. (See findings in tag A-0144).

b) Failing to ensure a patient with oxygen tubing that had been admitted with suicidal ideations was observed in constant line of sight for 1 (#3) of 2 (#1, #3) current patients reviewed with oxygen tubing out of a total of 15 sampled patients. (See findings tag A-0144).

c) Failing to ensure a suicide/homicide risk assessment had been completed by the RN before an observation level had been ordered by the physician who had not yet assessed the patient for 3 (#1, #3, #4) of 3 patients reviewed for risk assessments and ordered observation levels out of a total of 15 sampled patients. (See findings tag A-0144).

d) Having patients at risk for danger to self and others with inconsistent and inconclusive suicide risk assessments (See findings tag A-0144).

e) Assigning all newly admitted psychiatric patients every 15 minute monitoring prior to a risk assessment being completed which may have indicated a higher level of observation should have been maintained for the safety of the patient for 3 (#1,#3,#15) of 11 (#1-#10, #15) current patients reviewed out of a total of 15 sampled patients. (See findings tag A-0144).

f) Failing to ensure Patients rooms did not have safety risks for 11 of 11 patient rooms (See findings tag A-0144).


2) Failing to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

a) Failing to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to ensure admission orders were not written by a licensed practical nurse instead of a licensed independent practitioner privileged to write orders for 1(#2) of a total of 15 sampled patients (See findings tag A-0395).

b) Failing to ensure a RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs as evidenced by having 3 MHTs who were assigned the observation of patients on direct line of sight to also be assigned the observation of other patients in separate rooms or on a different hall of the hospital on 1 of 1 days sampled (See findings tag A-0397).


3) Failing to meet the requirements of the Condition of Participation for Radiologic Services as evidenced by:

a) Failing to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by the Director of Radiology (S18MD), appointed by the Governing Body, was not a radiologist (See findings tag A-0528), and;

b) Failing to ensure all radiological interpretations were made by radiologists who were credentialed and privileged members of the Medical Staff. This deficient practice was evidenced by no documented evidence of radiologists, who interpreted x-rays performed on hospital patients, having been granted privileges. Hospital radiological exams were interpreted by 7 radiologists (S23MD, S24MD, S25MD, S26MD, S27MD, S28MD, and S29MD) from Company A, that did not have approved privileges in the hospital (see A-0546).





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