HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure the physical environment was maintained to assure the safety of patients as evidenced by having stained ceiling tiles throughout the DSU and CAH and having dust build-up on ceiling vents in Room "l", build-up of lint in the dryer vent in Room "i", and accumulated water condensation in the fluorescent light covering in Room "a".
Findings:

Observation on 08/21/17 at 12:40 p.m. revealed an accumulation of dust on the ceiling vent in Room "l". Further observation revealed the vent in the dryer in Room "i" had an accumulation of lint.

Observation on 8/22/17 at 3:15 p.m. of the medical record storage room revealed 5 ceiling tiles with brown and black stains.

Observation on 8/22/17 at 3:20 p.m. of the nurses' station for inpatients revealed 4 ceiling tiles that had brown spots.

Observation on 08/23/17 at 8:58 a.m. on the DSU revealed stained ceiling tiles in the nursing station and Rooms "a", "b", "c", "d", "e", "f", "g", "h", "i", "j", and "l". Further observation revealed the ceiling tile in Room "g" had a ceiling tile that was torn around the sprinkler head, and one tile had a dark brown stain that looked like mold. Further observation revealed the fluorescent light covering in Room "a" had a collection of water in it.

In an interview during the observations on 08/21/17 at 12:40 p.m., S8PsychMgr confirmed the findings.

In an interview on 8/22/17 at 3:15 p.m. with S6MedRec, she said the tiles were discolored in the medical record storage room because of water damage. S6MedRec said the black spots appeared to be mildew or mold.

In an interview on 08/23/17 at 9:15 a.m., S22 MainDir indicated the DPU is a portable building that when set up they put a fresh air return (certain climates you can open it up and it can bring air into the system). He further indicated there is a control valve that controls the amount of air flow that's brought into the system. S22MainDir indicated with the humidity , it gets hot and fresh air is brought into the air conditioning system that causes condensation. he further indicated he had closed the control valve which slowed it down, but they have to get to the right mixture of fresh air coming into the system. He indicated he will probably have to close it off if there's wet tiles. He further indicated he wasn't aware there wet/stained tiles on the DPU since they had changed tiles at the beginning of summer. He further indicated he would have to check about the possibility of mold and the accumulation of water in the fluorescent light fixture.






30364

Based on record review and interview, the CAH failed to ensure there was an annual inspection and approval by the State Fire Marshal.

Findings:

Review of the CAHs most recent Office of State Fire Marshal report revealed the inspection date was 7/6/16.

In an interview on 8/23/17 at 8:20 a.m. with S2DON, she verified the Fire Marshall inspection should be done annually. She also verified the current inspection should have been completed by 7/6/17.

Based on observations, record reviews, and interviews, the governing body failed to implement and monitor policies governing the hospital's total operation and for ensuring that those policies were administered so as to provide quality health care in a safe environment as evidenced by:
1) Failing to ensure a safe patient environment on the DPU by having multiple ligature and safety risks present throughout the unit. There was a census of 8 patients with 2 patients who were suicidal and 2 patients who were violent.
2) Failing to ensure medical staff reappointments were conducted in accordance with Medical Staff and Governing Body By-laws for 6 (S4MD, S9MD, S17MD, S18MD, S19MD, S20MD) of 6 physician credentialing files reviewed from a total of 31 credentialed physicians.
3) Failing to accurately identify the governing body members and failing to implement the Governing Body By-laws by having 5 members rather than at least 7 members as required by the By-laws.
Findings:

1) Failing to ensure a safe patient environment on the DPU by having multiple ligature and safety risks present throughout the unit:
Observations on the DPU on 08/21/17 at 12:40 p.m. with S8PsychMgr present revealed the following safety and ligature risks:
1) All ceiling tiles in patient rooms (Rooms "a", "b", "c", "d", "e", "f"), bathrooms, and other areas of unit except Room "h" were not secured and able to be lifted which presented a risk for elopement and hiding contraband;
2) Toilets in all patient bathrooms, Room "h", and throughout the unit were not contained; the sink plumbing in Room "m" was not contained;
3) All entrance doors to patient rooms, bathrooms, Room "h" (and ante room and bathroom), and Rooms "g", "i", "j", "k", "l" and "m" had 3 hinges separated with enough space to be a ligature risk;
4) Paper towel dispenser in the following rooms had rust build-up (infection control issue) and sharp edges which were a safety risk - Rooms "b", "c", "e", "e", "h" (bathroom), "j", and "l";
5) All lavatory faucets in patient bathrooms and Rooms "h", "j", "l", and "m" were not ligature-proof, as well as the shower valves in Rooms "j" and "l";
6) All door handles to patient entrance doors, patient bathrooms, and Rooms "g", "h" (ante room and bathroom also), "j", "k", "l", and "m" had handles that were not ligature-proof;
7) A 19 ounce can of Lysol Disinfectant Spray was on the counter in the bathroom of Room "h";
8) Screws to all door handles and door panels, the trim surrounding the glass outside the door of Room "h", hall electrical outlets, shower rail in Room "j", the light receptacle and call box in Room "k", the upper shelf and upper wall shelf in Room "k", the picture frame in the hall leading to the lobby, the light receptacle at the lobby entrance door, the light receptacle in Room "m", and the electrical outlets under the cabinet and 6 wall electrical outlets in the Room "m" were not tamper-resistant;
9) Bed alarm was attached to the clothing of a patient lying in bed in Room "a" by an approximate 2 feet length of string that presented a ligature risk (patient with alarm was not on suicide precautions, but his roommate was);
10) All patient beds had exposed metal springs on which the mattress was situated and 2 hand cranks that presented a risk for injury/ligature.

In an interview on 08/21/17 at 12:40 p.m. during the tour, S8PsychMgr indicated the census was 8 with 2 patients who were suicidal and 2 patients who were violent. She further indicated the electrical outlets in patient rooms were controlled by a switch at the nursing station, so they were currently turned off. Observation at the end of the tour revealed the electrical outlet switch in the nursing station for Room "a" (where a patient on suicide precautions is housed) was on. S8PsychMgr indicated all switches were supposed to be off, unless the patient needed to be on an oxygen concentrator, at which time the patient would be placed on 1:1 observation. She confirmed that there was no oxygen concentrator in use in Room "a". S8PsychMgr confirmed the above findings as ligature/safety risks.

2) Failing to ensure medical staff reappointments were conducted in accordance with Medical Staff and Governing Body By-laws:
Review of the "Bylaws Of The Medical Staff", presented as the current bylaws by S24HRD, revealed that the reappointment process shall be followed in accordance with Section 2 of Article V relating to the recommendations on applications for initial appointment. Review of Section 2 Article V revealed the following process:
a) After receipt of the completed application for membership, and at the next medical staff meeting, the Medical Staff shall make a recommendation to the Governing Body. All recommendations to appoint must also specifically recommend the clinical privileges to be granted.
b) Prior to making the above report and recommendation, the Medical Staff shall examine the the evidence of character, professional competence, qualifications, and ethical standing and shall determine, through information contained in references given by the applicant, whether the applicant has established and meets all necessary qualifications for the category of membership and the clinical privileges requested.
c) When the Medical Staff recommendation is favorable, the Administrator shall forward it, together with all supporting documentation, to the Governing Body.
d) The Governing Body shall act in the matter at its next meeting following receipt of a favorable recommendation from the Medical Staff.
Further review of the By-laws revealed that every application for staff appointment and reappointment must contain a request for the specific clinical privileges desired by the applicant.

S4MD
Review of S4MD's credentialing file revealed he was the Medical Director, and his appointment date was January 2015 to December 2016. The most recent application in the file was dated 12/10/14. The most recent privilege request was dated 12/13/12. Further review revealed his CDS license was queried on 08/22/17, the day the file request was made by the surveyor, with the expiration date of 05/18/18. Further review revealed the liability coverage expired on 05/26/17. References in the file were from 01/29/13 and 12/10/12. The most recent NPDB query was conducted on 12/08/14. Further review revealed no documented evidence that all required content at the time of reappointment in accordance with the Medical Staff By-laws was in S4MD's credentialing file. There was no documented evidence that he was reappointed prior to the expiration of his appointment in December 2016.

S9MD
Review of S9MD's credentialing file revealed he was a psychiatrist who was the Clinical Director of the DPU, and his appointment was for January 2016 to December 2017. Further review revealed his application was dated 02/08/16, after he had been appointed. Further review revealed his medical license that expires on 05/31/18 was not verified. There was no documented evidence of medical school/intern/residency, references, affiliations. The NPDB query was conducted on 10/04/16, after his appointment date. Review of the American Medical Association Profile review conducted on 09/22/16 revealed no board certifications reported (required for Clinical Director position in DPU). Further review revealed no documented evidence of privileges requested and approved when he was appointed.

S17MD
Review of S17MD's credentialing file revealed his specialty was Internal medicine, and his appointment was from January 2015 to December 2016. There was an application dated 01/09/17. The most recent privilege request was dated 12/18/14. The most recent NPDB query was conducted on 12/17/14. Further review revealed verification of his medical license and CDS license were conducted on 08/22/17, the day the file request was made. His liability coverage expired on 04/18/17. There was no documented evidence that he was reappointed prior to the expiration of his appointment in December 2016.

S18MD
Review of S18MD's credentialing file revealed she was a Radiologist, and her appointment was January 2015 to December 2016. Further review revealed an application dated 10/17/16. The most recent privilege request was 12/18/14. Further review revealed verification of her medical license and CDS license were conducted on 08/22/17, the day the file request was made. Review of the peer references revealed they were from 2008. The most recent NPDB was conducted on 12/08/14, and the AMA Profile was conducted on 12/15/14. There was no documented evidence of current re-appointment and privileges as Director of Radiological Services.

S19MD
Review of S19MD's credentialing file revealed he was a Pathologist, and his appointment was 01/01/14 to 12/31/15. The most recent application was dated 10/02/15. His medical license verification was conducted on 08/22/17, the day the file request was made. His liability coverage expired on 05/12/17. The most recent AMA Profile review was conducted on 12/08/15. There was no documented evidence that S19MD was reappointed prior to the expiration of his appointment on 12/31/15, and there was no documented evidence that he was privileged as the hospital's Director of Laboratory Services.

S20MD
Review of S20MD's credentialing file revealed he was an emergency room physician, and his appointment was January 2015 to December 2016. The most recent request for privileges was dated 12/18/14. His medical license verification and CDS license verification were conducted on 08/22/17, the day the file request was made. Further review revealed his DEA license expired 01/31/17, his ACLS certification expired 03/03/17, and his PALS certification expired 03/01/17. There was no documented evidence that S20MD was reappointed prior to the expiration of his appointment in December 2016.

Review of the Medical Staff meeting minutes of 12/20/16 revealed that S4MD motioned that all active, courtesy, and consulting staff be reappointed, and the motion was seconded.

Review of the Governing Body meeting minutes of 12/29/16 revealed no documented evidence that any physicians were reappointed.

In an interview on 08/22/17 at 2:50 p.m., S6MedRec indicated she was responsible for credentialing as of about 1 month ago. She further indicated she had received no training as of the time of this interview.

In an interview on 08/23/17 at 7:55 a.m. with S6MedRec and S24HRD present, S6MedRec indicated she wasn't aware the above-listed physicians weren't reappointed. S24HRD confirmed the current medical and CDS license verifications were done and printed on 08/22/17 after the surveyor requested the credentialing files. She further indicated she had done credentialing for the past year and had about 6 hours of training from the previous administrator. During the interview S24HRD presented the governing body and medical staff meeting minutes. She confirmed the governing body meeting minutes didn't include physicians who were credentialed. She confirmed that the files that would have been reviewed for reappointment by the Medical Staff at the time of the meeting on 12/20/16 didn't have all required content in accordance with bylaws. S24HRD confirmed the above-listed physicians did not have current appointment to the Medical Staff and were not currently privileged.

In an interview on 08/23/17 at 8:40 a.m., S1Adm indicated they would "fix it" when informed that the above-listed physicians had not been reappointed prior to their appointment expiring.

3) Failing to accurately identify the governing body members and failing to implement the Governing Body By-laws:
Review of the list of the Board of Directors, contained in the Governing Body By-laws manual presented as the current governing body by-laws by S2DON, revealed that there 7 members.

Review of the "Governing Body Bylaws Of DeQuincy Memorial Hospital", presented as the current by-laws by S2DON, revealed that the governing body will consist of no less than 7 members.

In an interview on 08/22/17 at 2:30 p.m., S2DON indicated the list of Board of Directors wasn't accurate, because S16GovBody and S15GovBody were no longer members. She confirmed there were currently only 5 members on the Board of Directors rather than 7 as required by the governing body by-laws.

In an interview on 08/23/17 at 8:40 a.m., S1Adm confirmed that S16GovBody and S15GovBody were no longer members of the governing body.

Based on observation, policy review and staff interviews, the CAH (Critical Access Hospital) failed to ensure health care services were furnished in accordance with written policies. This deficient practice was evidenced by failing to ensure a patient's representative received a written response from the CAH after filing a grievance for 1 of 1 grievance reviewed.

Findings:

Review of the CAH policy titled Patient Complaint and Grievance Process revealed in part:
The Patient Advocate/Grievance Coordinator shall send a written notice to the patient which will include the following elements (the target timeline for a written notice in seven days after receipt of the concern): The name of the patient advocate, the steps taken to investigate and resolve the grievance, the final result of the complaint and grievance process, and the date of completion.

Review of a grievance written to the CAH dated 7/1/17 revealed a patient had taken her six year old son to the Emergency Department because he had broken his arm. Further review revealed she alleged a nurse and a physician had yelled at her son to stop crying so she left and went to another hospital for treatment.

In an interview on 8/22/17 at 12:03 p.m. with S2DON, she verified she only had 1 grievance in the past year. She verified a letter had not been sent to the complainant

Based on policy review, observation and interview, the CAH failed to ensure the drug storage area was managed with accepted professional principles. This deficient practiced is evidenced by failing to secure the door to the pharmacy allowing access to medications by unauthorized individuals.

Findings:

Review of the CAH policy titled Security Drug Storage Areas, revealed in part:
Drugs shall be kept in locked storage or be inaccessible to unauthorized individuals.

In an observation on 8/22/17 at 9:35 a.m., the door from an unsecured hallway to the pharmacy was propped open.

In an observation on 8/22/17 at 9:45 a.m., the door to the pharmacy remained propped open. Surveyor was able to walk into the pharmacy and had access to 5 shelving units containing medications without a staff member aware.

In an interview on 8/22/17 at 9:55 a.m. with S2DON, she verified the door to the pharmacy should have always remain secured.

Based on record review and interview, the CAH failed to ensure documentation of medical errors, including notification to the practitioner was in patient's medical records for 3 (#18, #19, and #20) of 3 patients out of a total sample of 20 reviewed with hospital discovered medical errors.

Findings:

Review of the hospital policy and procedure titled Errors: Drug Administration, Policy Number 15-08, revealed in part:
Initial Action, Drug administration errors shall be reported immediately to the practitioner who ordered the drug.
Recording in Patient Record, The drug administered in error or omitted in error and the action taken shall be properly recorded in the patient's medical record.

Patient #18
Review of the physicians order for patient #18 revealed an order for Ativan 2 mg po tid, and Keppra po tid. Review of the medication administration record revealed the dose had not been given to the patient on 04/04/17 at 5:00 a.m. Further review revealed no documented evidence of the medication error or physician notification in the medical record.

Patient #19
Review of the physicians order for patient #19 revealed an order for Sinemet 25/100mg 3 tabs po q hs. Review of the medication administration record revealed the patient was given 1 tablet on 03/08/17 at 10:48 p.m. Further review revealed no documented evidence of the medication error or physician notification in the medical record.

Patient #20
Review of the Incident Report provided by S2DON revealed patient #20 was given Mag Ox 400mg po on 05/18/17 at 12:28 p.m. with no documented physicians order for the medication. Further review revealed no documented evidence of the medication error or physician notification in the medical record.

In an interview on 08/22/17 at 2:20 p.m. with S2DON, she verified the above referenced and identified medical errors should have been documented in the patient's medical records.

Based on record reviews and interview, the hospital failed to ensure it followed the OPH guidelines for controlling communicable diseases of personnel as evidenced by failure to have documented evidence of current TB test results for 4 (S9MD, S17MD, S18MD, S19MD) of 6 physician files reviewed for TB results and 1 (S25XRay) of 14 personnel files reviewed for TB results.
Findings:

Review of the hospital policy titled "Employee Health", presented as a current policy by S24HRD, revealed that an annual check-up of a chest x-ray/PPD test will be required from each employee of the hospital. There was no documented evidence that the policy required physicians to be tested and that the policy followed the OPH guidelines for TB testing.

Review of "Title 51 Public Health - Sanitary Code Chapter 5. Health Examinations for Employees, Volunteers and Patients at Certain Medical and Residential Facilities" revealed that all persons prior to or at the time of employment at any medical or 24-hour residential facility requiring licensing by LDH shall be free of TB in a communicable state as evidenced by either: 1) a negative purified protein derivative (PPD) skin test for TB, five tuberculin unit strength, given by the Mantoux method or blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration (FDA); 2) a normal chest x-ray, if the skin test or a blood assay is positive; or 3) a statement from a licensed physician certifying that the individual is non-infectious if the x-ray is other than normal. In order to remain employed, the employee, who has a negative purified protein derivative skin test for tuberculosis, five tuberculin unit strength, given by the Mantoux method, or a negative result of a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration, shall be rescreened annually by one of the following methods: purified protein derivative skin test for tuberculosis, five tuberculin unit strength, given by the Mantoux method, or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration remains negative, or a completed questionnaire asking of the person pertinent questions related to active tuberculosis symptoms, including, but not limited to: do you have a productive cough that has lasted at least 3 weeks? (Yes or No), are you coughing up blood (hemoptysis)? (Yes or No), have you had an unexplained weight loss recently? (Yes or No), have you had fever, chills, or night sweats for 3 or more days? (Yes or No). Any employee converting from a negative to a positive purified protein derivative skin test for tuberculosis, five tuberculin unit strength, given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration or having indicated symptoms of active tuberculosis revealed by the completed questionnaire, which indicates the person may have tuberculosis in a communicable state shall be referred to a physician and followed. All initial screening test results and all follow-up screening test results shall be kept in each employee's or volunteer's health record.

Review of the credentialing files of S9MD, S17MD, S18MD, and S19MD and the personnel file of S25XRay revealed no documented evidence of a current TB test result.

In an interview on 08/23/17 at 10:45 a.m., S24HRD confirmed the above findings. She indicated that S25XRay told her she had never tested positive for TB and that she always had a chest x-ray rather than have a TB test administered in accordance with OPH guidelines.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to ensure the LPN notified him/her of a patient with a blood sugar reading of 37, assess the patient, report the finding to the physician, and obtain physician orders for treatment for 1 (#9) of 1 patient record reviewed with a low blood sugar reading from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
2) The RN failed to assess and document a patient's wound including wound measurements and appearance of the wound and surrounding tissue and perform wound care as ordered by the physician for 1 (#2) of 1 patient record reviewed with a wound from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
3) The RN failed to ensure a complete and accurate suicide/homicide/violence risk assessment was conducted during the admission process for 3 (#1, #2, #10) of 4 (#1, #2, #9, #10) patient records reviewed for suicide/homicide/violence risk assessments from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
4) The RN failed to conduct a complete admit assessment for 1 (#2) of 4 patient records reviewed for admit assessments by the RN from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
5) The RN failed to ensure the MHT observation sheets included the special precautions ordered for each patient as evidenced by failing to include suicide precautions for 2 (#1, #2) of 4 (#1, #2, #9, #10) patient records reviewed for accurate MHT observation sheets from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
Findings:

1) The RN failed to ensure the LPN notified him/her of a patient with a blood sugar reading of 37, assess the patient, report the finding to the physician, and obtain physician orders for treatment:
Review of Patient #9's physician orders revealed an order on 08/18/17 at 9:00 a.m. to do Accuchecks before meals and at bedtime. Before meal sliding scale coverage was order and bedtime sliding scale coverage was ordered only for signs or symptoms of hyperglycemia or hypoglycemia. There was a physician order to give Glucagon 1 milligram intramuscularly if the blood sugar was less than 60 and the patient was unable to swallow. The order didn't include what action to take for a blood sugar less than 60 if the patient could swallow.

Review of the blood sugar results revealed the blood glucose was 37 on 08/19/17 at 6:24 a.m., and S13LPN gave "juice with sugar and bite of icing." There was no documented evidence that S13LPN notified the RN or physician of the blood glucose of 37, that an assessment of Patient #9's condition was documented by S13LPN or a RN, and the blood glucose was not re-assessed until the next scheduled time at 11:50 a.m.

In an interview on 08/22/17 at 9:55 a.m., S8PsychMgr indicated there's no documented evidence that S13LPN reported the low reading to the RN or physician. She confirmed the hospital had no protocol for treatment of blood glucose below 60 when the patient is not unconscious. She confirmed the RN and physician should have been notified, the RN should have assessed the patient, orders should have been obtained for treatment, and the blood glucose should have been re-assessed sooner than more than 5 hours later.

2) The RN failed to assess and document a patient's wound including wound measurements and appearance of the wound and surrounding tissue and perform wound care as ordered by the physician:
Review of the hospital policy titled "Skin/Wound care Protocol",presented as a current policy by S8PsychMgr, revealed that the RN will document initial wound findings on the Wound Evaluation Form. The documentation will include a wound description of location, type, where acquired, stage, length, width, depth, wound bed description, drainage, odor, surrounding skin, and pain. The wound description will be documented on the Wound Evaluation Form when wound care is performed.

Review of Patient #2's admit assessment conducted by S10RN on 08/19/17 at 8:45 p.m. revealed documentation of a wound to the right "outer ankle Stage II." There was no documented evidence of an assessment of the wound that included measurements and the appearance of the wound and surrounding tissue, presence or absence of drainage, and presence or absence of odor. Review of the entire medical record revealed no documented of such an assessment as of the time of the chart review on 08/21/17 at 2:55 p.m. There was no documented evidence that the physician was notified of the wound and orders for treatment obtained.

Review of 2 pictures of wounds, presented by S8PsychMgr, revealed the dates stamped on the photograph was 04/14/12 (camera date was not accurate), and there was no documented evidence of the sites of each wound and the signature and title of the photographer.

Review of the physician orders revealed an order received on 08/20/17 at 1:00 p.m. to clean the wound to the right ankle topically with wound cleanser, then place Thera Honey Foam Flex to the wound bed only, cover with non-stick Telfa, and wrap with Kerlix to secure.

Review of the nursing notes revealed no documented evidence that wound care was performed as ordered on 08/21/17.

In an interview on 08/2/17 at 9:15 a.m., S8PsychMgr confirmed there was no documented evidence of wound measurements in the medical record and an assessment by a RN. She also confirmed the wound was identified on admit on 08/19/17 at 8:05 p.m., and the physician was not notified for orders until 08/20/17 at 1:00 p.m. S8PsychMgr confirmed there was no documented evidence that wound care was performed on 08/21/17 as ordered.

3) The RN failed to ensure a complete and accurate suicide/homicide/violence risk assessment was conducted during the admission process:
Review of the policy titled "Suicide/Homicide Risk Assessment", presented as a current policy by S8PsychMgr, revealed that the admitting nurse completes the suicide and homicide risk screening form as part of the initial comprehensive integrated assessment on admission and communicates the findings to the physician. On order to determine the level of risk as high. moderate, or low, the risk screening includes risk factors, protective factors, and mitigating factors.

Patient #1
Review of Patient #1's nursing assessment revealed S10RN conducted the suicide and homicide risk screen on 08/20/17 at 8:50 p.m. Further review revealed no documented evidence that the suicide and homicide protective factors were assessed, and there was no documented evidence that the suicide and homicide risk level was determined as evidenced by these sections being blank on the form. There was no documented evidence that the physician was notified of the assessment findings by S10RN.

Patient #2
Review of Patient #2's nursing assessment revealed S10RN documented that she was the admitting nurse, but there was no documented evidence of the signature and date of S10RN at the conclusion of the assessment. Further review revealed no documented evidence that the suicide and homicide risk factors and protective factors were assessed, and there was no documented evidence that the suicide and homicide risk level was determined as evidenced by these sections being blank on the form. There was no documented evidence that the physician was notified of the assessment findings by S10RN.

Patient #10
Review of patient #10's nursing assessment revealed S10RN conducted the suicide and homicide risk screen on 08/16/17 at 12:30 a.m. Review of the suicide risk level screen revealed risk and protective factors were identified with no documented evidence of the suicide risk level determination. Review of the homicide risk level screen revealed no documented evidence that suicide and protective factors were identified, and there was no risk level assigned by S10RN. Further review revealed no documented evidence that the physician was notified of the assessment findings by S10RN.

In an interview on 08/22/17 at 10:20 a.m., S8PsychMgr confirmed the above findings.

4) The RN failed to conduct a complete admit assessment:
Review of the policy titled "Comprehensive Interdisciplinary Assessment (CIA) with Multi-Treatment Integration", presented as a current policy by S8PsychMgr, revealed that in the absence of a pre-arrival assessment by an Admitting professional/Liaison the Unit Nurse will complete the Initial Assessment and Level of care Determination and notifies the physician of findings.

Review of Patient #2's medical record revealed no documented evidence that the Intake Screen and Initial Level of Care Determination was not completed prior to or at the time of admit.

In an interview on 08/22/17 at 9:15 a.m., S8PsychMgr indicated the intake screen and initial level of care determination is done by her. She further indicated when she is not present on weekends and after hours, it is supposed to be done by the admit RN. S8PsychMgr confirmed that the admit RN did not complete the intake assessment and level of care determination at admit.

5) The RN failed to ensure the MHT observation sheets included the special precautions ordered for each patient:
Patient #1
Review of Patient #1's medical record revealed he was admitted on 08/20/17 at 8:30 p.m. with physician orders for suicide and fall precautions. Review of His "Close Observation Check Sheet" dated 08/20/17 that covered from 7:30 a.m. on 08/20/17 to 7:15 a.m. on 08/21/17 revealed no documented evidence that suicide precautions was checked as one of the precautions.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 08/19/17 at 9:00 p.m. with physician orders for suicide and fall precautions. Review of her "Close Observation Check Sheet", one not dated (written "new admit") and one dated 08/20/17, revealed no documented evidence that suicide precautions was checked as one of the precautions.

In an interview on 08/22/17 at 9:15 a.m., S8PsychMgr confirmed the above findings.

Based on record review and staff interview, the CAH failed to ensure all medications were administered in accordance with physician's orders and accepted standards of practice for 2 (#8, #11) of 10 patients reviewed for medication administration out of a total sample of 20 patients.

Findings:

Patient #8
Review of Patient #8's sliding scale orders revealed for a blood glucose between 151- 200 that 4 units of Regular Insulin was to be given.

Review of Patient #8's Diabetic Flow Sheet revealed blood glucoses of 180 on 8/19/17 at 6:05 a.m. and 164 at 8:33 p.m. Further review revealed no documentation of insulin administration.

In an interview on 8/22/17 at 9:45 a.m. with S2ADON, he verified the insulin doses mentioned above had not been documented as having been given.

Patient #11
1) Review of Patient #11's medical record revealed Lopressor (medicine to decrease blood pressure) had been administered to the patient after the following blood pressures were documented on the evening shift:
8/12/17- 75/41
8/14/17- 81/59
8/15/17- 79/49

In an interview on 8/22/17 at 8:50 a.m. with S25LPN, she said if the systolic blood pressure was below 100 the nurses should have held the dose of and notified the doctor.

In an interview on 8/22/17 at 9:30 a.m. with S2DON, she said she would expect the nursing staff to notify the physician before administering a blood pressure medication if the systolic was below 100.

In an interview on 8/22/17 at 10:00 a.m. with S4MD, he verified he should have been notified of blood pressures with a systolic less than 90.

2) Review of Patient #11's Medication Administration Record dated 8/18/17 revealed an entry that the scheduled dose of Lopressor had been held because of a blood pressure of 95/53. There was no documentation of notification to the physician that the dose had been held or an order to hold the dose.

In an interview on 8/22/17 at 10:00 a.m. with S4MD, he verified the dose of Lopressor on 8/18/17 at 8:48 p.m. should not have been held without an order from him.

30364

Based on record review and interview, the CAH failed to ensure nursing care plans were developed and kept current for each inpatient for 3 (#4, #6, #8) of 10 patients reviewed for care planning out of a total sample of 20.

Findings:

Review of the CAH policy titled Care Planning revealed in part:
Nursing staff shall develop a plan of care for each patient within 24 hours of admission.
Care planning shall be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable.

Patient #4
Review of the medical record for patient #4 revealed the patient was admitted to the hospital on 08/17/17 diagnosis of dehydration, UTI (urinary tract infection), and hypotension. Further review of admission orders dated 08/17/17 revealed physician admitted patient to acute care for Dehydration, Hypotension, Syncope, UTI, and DM. Initial nursing assessment completed on 08/17/17 included care plan goals and interventions for UTI, but did not address goals or interventions for all admitting diagnosis.

Patient #6
Review of Patient #6's medical record revealed he had been admitted on 8/19/17 and Discharged 8/21/17. His diagnosis included Leukocytosis, PT (prothrombin time) and INR (international normalized ratio) elevated, and falls.

Review of Patient #6's care plans dated 8/19/17 through 8/21/17 revealed the two problems identified were increased INR and Leukocytosis. Falls had not been identified as a problem. Further review revealed no interventions had been selected for the identified problems.

Patient #8
Review of Patient #8's medical record revealed she was admitted on 8/14/17 and was a current patient. Her diagnosis included post CVA (Cerebrovascular accident) with right sided weakness, Hypertension, and difficulty swallowing with PEG tube (feeding tube).

Review of Patient #8's medical record revealed she had problems identified for Sensory Perception Disturbance related to Cerebrovascular accident, Impaired Physical Mobility Related to Weakness, and Skin Integrity Risk. No interventions or goals were listed and having difficulty swallowing was not care planned.

In an interview on 8/21/17 at 3:40 p.m. with S2ADON, he verified that care plans should have included all of the patients' problems and had interventions for the problems.

30364

Based on record review and interview, the CAH failed to ensure all medical record entries for patient's receiving health care services at the hospital were complete. This deficient practice was evidenced by failure to ensure all medical record entries were authenticated, dated, and timed for 3 (#4, #8, #11) of 10 patients sampled for timing medical record entries out of a total sample of 20.

Findings:

Review of the CAH policy titled Documentation Policy revealed in part:
Medical records shall be documented legibly, dated, timed and signed.
Physician signatures must be legible, dated and timed.

Patient#4
Review of Patient #4's medical record revealed Telephone/Verbal orders that had been authenticated by S4MD but his signature had not been dated or timed on orders written on the following dates:
08/17/17 at 8:15 p.m. and 8:30 p.m.
08/18/17 at 10:05 a.m., 1:00 p.m. and 7:00 p.m.
08/20/17 at 7:56 a.m., 10:21 a.m. and 8:30 p.m.

Patient #8
Review of Patient #8's medical record revealed Telephone/Verbal orders that had been authenticated by S4MD but his signature had not been dated or timed on orders written on the following dates:
8/14/17 at 3:30 p.m. and 8:30 p.m.
8/15/17 at 10:00 a.m., 8:00 a.m., 1:00 p.m., 7:00 p.m., and 11:30 p.m.
8/16/17 at 12:20 a.m., 7:20 a.m., 7:25 a.m., 9:30 a.m., 9:45 a.m., 10:05 a.m., 12:10 p.m.

Patient #11
Review of Patient #11's medical record revealed Telephone/Verbal orders that had been authenticated by S4MD but his signature had not been dated or timed on orders written on the following dates:
8/10/17 at 5:15 p.m.
8/11/17 at 1:07 a.m.
8/12/17 at 7:00 a.m., 9:20 a.m., 1:50 p.m., and 3:10 p.m.
8/13/17 at 8:00 a.m., 3:55 p.m.
8/15/17 at 10:35 a.m. and 1:00 p.m.

In an interview on 8/22/17 at 10:00 a.m. with S4MD, he verified he should have been dating and timing his signatures in the medical records.

Based on record review and interview, the hospital failed to implement its written admission criteria as evidenced by having a patient (#9) admitted under the age criteria with no documented evidence of justification as required by hospital policy for 1 (#9) of 1 DPU patient chart reviewed for meeting admission criteria from a total of 7 DPU medical records reviewed with a total survey sample of 20 medical records.
Findings:

Review of the policy titled "Admission Criteria/Continued Stay Criteria", presented as a current policy by S8PsychMgr, revealed that the age requirement for admission to the DPU was 50 years or above. Further review revealed that the Medical Director or Administrator was authorized to waive any criteria for admission with documented clinical justification.

Review of Patient #9's medical record revealed she was 44 years old. Review of the psychiatric evaluation and physician progress notes revealed no documented evidence of justification for waiving the admission criteria for Patient #9.

In an interview on 08/22/17 at 9:55 a.m., S8PsychMgr indicated the physician can override the age requirement for admission. After reviewing the medical record of Patient #9, S8PsychMgr confirmed there was no documented justification by S9MD.

Based on interview, the hospital failed to ensure psychological services were available to patients on the DPU as evidenced by failure to have a qualified psychologist employed or contracted to provide psychological services when needed.
Findings:

In an interview on 08/23/17 at 11:20 a.m., S8PsychMgr indicated the DPU did not have a psychologist employed or contracted to provide psychological services.

Based on record reviews and interview, the hospital failed to ensure each psychiatric evaluation included a medical history that included allergies as required on the hospital's psychiatric form as evidenced by failure to have documented evidence that allergies were reviewed by S9MD during the psychiatric evaluations conducted for 4 (#1, #2, #9, #10) of 4 psychiatric evaluations reviewed from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S8PsychMgr, revealed that the evaluation included a review and evaluation of presenting illness and prior treatment experiences.

Review of the "Psychiatric Evaluation" form revealed "Past Medical History/Allergies" was a topic included in the evaluation.

Review of the "Psychiatric Evaluation" for Patients #1, #2, #9, and #10 revealed S9MD documented "see above" in the space next to "Past Medical History/Allergies." Review of the documentation above this section revealed no documented evidence that allergies were listed.

In an interview on 08/22/17 at 8:10 a.m., S8PsychMgr confirmed the above-listed psychiatric evaluations didn't include documented evidence of a review of allergies by S9MD. She indicated that S9MD would be available for interview on 08/23/17.

In an interview on 08/23/17 at 11:20 a.m., S8PsychMgr indicated that S9MD would not be available until later this day.

There was no opportunity presented to interview S9MD prior to the exit of the survey on 08/23/17 at 11:30 a.m.

Based on record reviews and interview, the hospital failed to ensure each psychiatric evaluation included an estimate of intellectual functioning, memory functioning, and orientation in accordance with hospital policy as evidenced by failure to have documented evidence of tests performed to assess such functioning and orientation as required by hospital policy for 4 (#1, #2, #9, #10) of 4 psychiatric evaluations reviewed from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S8PsychMgr, revealed that the evaluation included documentation of tests performed to assess cognitive functioning, memory, and estimated intellectual functioning in a sufficiently descriptive manner to establish diagnosis and an objective baseline for future comparison.

Review of the "Psychiatric Evaluation" form revealed the section titled "Attention And Concentration" a choice to check of wither intact or impaired. Further review revealed the form had sub-sections of "Digit Span", "Serial Subtractions", "Spell 5 letter word forward and backward", and "Other."

Review of the "Psychiatric Evaluation" for Patients #1, #2, #9, and #10 conducted by S9MD revealed no documented evidence that the sub-sections were completed as evidenced by blank spaces next to each sub-section.

In an interview on 08/22/17 at 8:10 a.m., S8PsychMgr confirmed the above-listed psychiatric evaluations didn't include documented evidence of tests being performed by S9MD to assess intellectual functioning, memory functioning, and orientation. She indicated that S9MD would be available for interview on 08/23/17.

In an interview on 08/23/17 at 11:20 a.m., S8PsychMgr indicated that S9MD would not be available until later this day.

There was no opportunity presented to interview S9MD prior to the exit of the survey on 08/23/17 at 11:30 a.m.

Based on record reviews and interview, the hospital failed to ensure each psychiatric evaluation included an inventory of the inpatients' assets in descriptive, not interpretive fashion as evidenced by failure to have documented evidence of assets stated in descriptive fashion for 4 (#1, #2, #9, #10) of 4 psychiatric evaluations reviewed from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
Findings:

Review of the policy titled "Psychiatric Evaluation", presented as a current policy by S8PsychMgr, revealed that the evaluation identified specific patient strengths and assets to enable the multidisciplinary treatment team to choose treatment modalities that best utilize these identified strengths and assets in the patient's treatment.

Review of the "Psychiatric Evaluation" form revealed the section titled "Strengths and Assets" had choices of the following to be selected: insight; education; motivated for treatment; supportive family/friends; capable of independent living; insight into problem; employment; articulate; adequate finances; community support; stable physical health; other.

Review of the "Psychiatric Evaluation" for Patients #1, #2, #9, and #10 conducted by S9MD revealed no documented evidence the patients' assets were written in descriptive fashion.

In an interview on 08/22/17 at 8:10 a.m., S8PsychMgr confirmed the above-listed psychiatric evaluations didn't include patient assets written in descriptive fashion. She indicated that S9MD would be available for interview on 08/23/17.

In an interview on 08/23/17 at 11:20 a.m., S8PsychMgr indicated that S9MD would not be available until later this day.

There was no opportunity presented to interview S9MD prior to the exit of the survey on 08/23/17 at 11:30 a.m.

Based on record reviews and interview, the hospital failed to ensure each inpatient's treatment plan included short-term and long-term goals that were measurable as required by hospital policy as evidenced by failure to have documented evidence of measurable goals for 4 (#1, #2, #9, #10) of 4 patients' written treatment plans reviewed from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
Findings:

Review of the policy titled "Treatment Planning; Integrated/Multidisciplinary"", presented as a current policy by S8PsychMgr, revealed that the the multidisciplinary team shall develop an integrated written, comprehensive treatment plan with specific goals and objectives. Further review revealed that goals were to be measurable.

Patient #1
Review of Patient #1's treatment plan for alteration in thought processes revealed the nursing goal was to "have an improvement in thought processes within 15 days." There was no documented evidence that the goal was measurable.

In an interview on 08/22/17 at 8:10 a.m., S8PsychMgr confirmed the above-listed goal was not stated in measurable terms.

Patient #2
Review of Patient #2's treatment plan for alteration in thought processes revealed the nursing goal was to "have an improvement in thought processes within 15 days." There was no documented evidence that the goal was measurable. Further review revealed the activity therapist did not develop measurable goals for this treatment plan. Review of the treatment plan for potential for self-harm revealed the nursing goal was to "be free from self-harm risk within 15 days" which did not include how this goal was to be measured. There was no documented evidence of goals developed by the activity therapist for this treatment plan. Review of the treatment plan for alteration in health maintenance revealed the nursing goal was to "demonstrate an understanding of treatment regimen to maintain medical condition at optimal level within 15 days" which did not include how this goal was to be measured. Review of the treatment plan for high risk for falls revealed the nursing goal was "consistently comply with activities that decrease risk within 15 days" which did not include how this goal was to be measured. Review of the treatment plan for impaired skin integrity revealed the nursing goal was "exhibit uncomplicated wound healing with an absence of infection within 15 days" with no documented evidence of how uncomplicated wound healing would be measured.

In an interview on 08/22/17 at 9:15 a.m., S8PsychMgr confirmed the above-written nursing goals were not written in measurable terms. She further indicated the activity therapist completed the assessment on 08/21/17 at 10:06 a.m., so goals and interventions should have been developed for activity therapy.

Patient #9
Review of Patient #9's treatment plan for alteration of mood revealed a nursing goal of "display a stabilizing of energy level within 7 days" with no documented evidence of how this goal would be measured to determine when it was met. There were no goals developed by the social worker for this plan. Review of the activity therapist's goals revealed "demonstrate increased tolerance to socially engage peers in a comfortable/relaxed manner" and "demonstrate increased concentration and focus during assignments/tasks." There was no documented evidence of how these goals would be measured. Review of the treatment plan for risk for violence revealed no documented evidence that goals had been developed by the social worker. The activity therapist goal for this plan was "demonstrate relaxed/socially appropriate behavior during tasks daily with no documented evidence of how this goal would be measured. Review of the treatment plan for alteration in health maintenance revealed the nursing goal was to "demonstrate an understanding of treatment regimen to maintain medical condition at optimal level within 2 weeks" which did not include how this goal was to be measured. Review of the treatment plan for high risk for falls revealed the nursing goal was "consistently comply with activities that decrease risk within 14 days" which did not include how this goal was to be measured.

In an interview on 08/22/17 at 9:55 a.m., S8PsychMgr confirmed the nursing and activity therapy goals were not written in measurable terms. She also confirmed there were no goals developed by the social worker.

Patient #10
Review of Patient #10's treatment plan for alteration in thought processes revealed the nursing goal was to "have an improvement in thought processes within 15 days." There was no documented evidence that the goal was measurable. Review of the activity therapy goals for this plan revealed the goals of "increase ability to modify symptomatology of _____ by increasing self-control, self-esteem and/or functional ability within 10 days", "demonstrate increased ability to complete tasks within 10 days", and "demonstrate increased tolerance to socially interact with peers without fearfulness or bizarre behavior patterns within 10 days" with no documented evidence of how each goal was to be measured to determine when it would be met. There was no documented evidence of social worker goals for this treatment plan and the plan for alteration of mood: mania behavior. Review of the treatment plan for alteration in health maintenance revealed the nursing goal was to "demonstrate an understanding of treatment regimen to maintain medical condition at optimal level within 15 days" which did not include how this goal was to be measured. Review of the treatment plan for high risk for falls revealed the nursing goal was "consistently comply with activities that decrease risk within 15 days" which did not include how this goal was to be measured.

In an interview on 08/22/17 at 10:20 a.m., S8PsychMgr confirmed the nursing and activity therapy goals listed above were not written in measurable terms, and there were no goals developed by the social worker.

Based on record reviews and interviews, the hospital failed to ensure each inpatient's individual comprehensive treatment plan included the specific treatment modalities to be utilized as evidenced by failure to include treatment modalities for 4 (#1, #2, #9, #10) of 4 patients' written treatment plans reviewed from a total of 6 DPU medical records reviewed with a total survey sample of 20 medical records.
Findings:

Review of the policy titled "Treatment Planning; Integrated/Multidisciplinary"", presented as a current policy by S8PsychMgr, revealed that the the multidisciplinary team shall develop an integrated written, comprehensive treatment plan that includes frequency of care and treatment and services.

Patient #1
Review of Patient #1's treatment plan for alteration in health maintenance and high risk for falls revealed no documented evidence that nursing interventions were developed.

Patient #2
Review of Patient #2's treatment plan for alteration thought processes - psychosis and potential for self-harm revealed no documented evidence that activity therapy interventions were developed.

Patient #9
Review of Patient #9's treatment plan for alteration of mood: mania behavior and risk for violence revealed no documented evidence that interventions were developed by the social worker.

Patient #10
Review of Patient #10's treatment plan for alteration thought processes - psychosis and alteration of mood: mania behavior revealed no documented evidence that interventions were developed by the social worker.

In an interview on 08/22/17 at 10:20 a.m., S8PsychMgr confirmed the above-listed treatment plans didn't have interventions developed by the nurse, activity therapist, and/or the social worker.