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Based on medical record review, hospital policy review, and staff interview, the medical staff failed to obtain consent related to psychotropic drugs in accordance with hospital policy in one of seven records reviewed (Patient #16).

Findings Included ....

A review of the hospital policy titled "Medication Informed Consents" last reviewed May 2020 showed " ...To ensure that a Patient's informed medication consent is obtained prior to the administration of a medication involving significant risk .... Psychotropic Medication: Medications administered for the purpose of affecting the central nervous system to treat psychiatric disorders or illnesses. These medication include but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications ...The Treating Practitioner should document that the informed consent process occurred and the Patient or Legal Representative should either sign the informed consent attached here to confirming that he/she has given informed consent or The treating Practitioner should document that the Patient or Legal Representative gave informed consent but indicated on the form "Refused (Or Unable) to sign: Verbal Consent given" in the blank for the Patient's signature ...."

The surveyor conducted a medical record review on 05/19/2022 at approximately 3:25 PM. The Physician admitted Patient #16's with diagnoses to include but not limited to Auditory Hallucination and Suicidal Ideation.

Review of the Psychiatric Admission Assessment dated 04/18/2022 at 2:18 PM showed "Psychiatric Medications ...: Risperdal 2mg (milligrams) po (by mouth) bid (twice a day) ...." Further review of the section showed the box allocated for "Reviewed side effects, risk benefits, alternatives of new medications listed above. Patient or legal representative provided signed and/or verbal consent" was left blank. Additionally, medical staff failed to obtain consent on 04/19/2022 and 04/20/2022.

Further review of the "Medication Administration Record" showed OlANzapin Tablet (Zyprexa) oral Twice Daily for psychosis ... Start: 4/17/2022 ..." and "risperiDONE Tablet (RisperDAL) oral Twice Daily for psychosis start: 4/18/2022."

The surveyor conducted a face-to-face interview on 05/24/2022 at approximately 2:43 PM with Employee #7, Director of Quality. When queried where psychotropic drug consent would be documented, she stated "It's documented on the physician progress noted. It would be documented under the treatment plan in the section psychiatric medications. Additionally, when queried if this is the only place the psychotropic drug consent would be documented she stated "Yes."

Based on medical record review, hospital policy review, and staff interview, the nursing staff failed to document monitoring for special precautions on the observation checklist in three of ten medical records reviewed (Patients #2, #15, and #18).

Findings Included....

Review of the hospital policy titled, "Sexual Victim Precaution", dated March 2020, showed "Risk for sexual victimization current and past is initially assessed for all patients upon intake ...Once the precaution, patients will be continually assessed for any potential for sexual victimization. Staff will update the Patient's Observation Rounds Check sheet to reflect the current Precaution and level of monitoring."

Review of hospital policy titled "Suicidal/Self-Injury Risk Precaution" last revised July 2019 showed " ...Attending Psychiatrist: Orders Suicide/Self-injury Precautions (SP) and level of monitoring as appropriate for the patient ... Nursing Staff/Treatment Team: Updates the Patient's observation rounds check sheet to reflect the current precautions and level of monitoring ...."

A review of the hospital policy titled "Inpatient Documentation Requirements" last revised June 2021 showed "Purpose: To delineate the responsibilities for documentation requirements in the inpatient medical record ...Precautions: 1. Nursing management will ensure the completion of safety checks on all patients, and that they are documented every 15 minutes ...."

1a. Review of the medical record on 05/23/2022 at approximately 2:44 PM showed Patient #2 was admitted to the facility under FD-12 (involuntary emergency hospitalization) by the Metropolitan Police Department for mental health evaluation and treatment for bizarre behaviors and complaint of an alleged sexual assault on 04/14/2022. Patient #2 was admitted with diagnoses to include but not limited to Unspecified Schizophrenia Spectrum, and Other Psychotic Spectrum Disorder and has a history of anxiety, depression, and childhood trauma related to sexual abuse.

Further review of the medical record showed in the "Alerts" section on the Patient Observation Sheet, Sexual Victimization Precautions were not selected to reflect the current precaution and level of monitoring.

The surveyor conducted a face-to-face interview on 05/23/2022 at approximately 2:44 PM with Employee #3, Assistant Chief Nursing Officer in regards to the documentation of special precautions. Employee #3 stated, "If there is a physician's order for special precautions, it should be documented on the observation checklist and the initial treatment plan or master plan. The treatment plan and observation checklist should address sexual victimization precautions. There is a process in place to avoid gaps in documentation by having the night shift staff check the charts for orders and select special precautions for the day shift to assess."


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1b. The surveyor conducted a medical record review on 05/23/2022 at approximately 2:10 PM. The Physician admitted Patient #18 with a diagnosis to include but not limited to Suicidal Ideation (SI).

Review of the Physician Orders dated 04/14/2022 at 12:27 showed "Precautions: Suicide Precaution."

Review of the "Patient observation Sheet" showed the box allocated for "Suicide/Self Injury Precautions" were left unmarked on 04/14, 04/15, and 04/16/2022. The patient observation sheets lacked documentation to reflect the patient's suicide precautions.

The surveyor conducted a face-to-face interview on 05/23/2022 at approximately 2:50 PM with Employee #3, Assistant Chief Nursing Officer. When queried regarding the standard practice for a patient on suicide precautions and if it is documented anywhere, she stated "If somebody comes in with suicidal precautions. Precautions are ordered by the physician. To let everyone know they need to be more mindful." Additionally, she stated it should have been updated on the patient observation sheet.

1c. The surveyor conducted a medical record review on 05/24/2022 at approximately 9:45 AM. The Physician admitted Patient #15's on 03/07/2022 with diagnosis to include but not limited to Post-traumatic Stress Disorder (PTSD), Anxiety, and Depression.

Review of the "Psychiatric Admission Assessment" dated 03/08/2022 showed "Safety Risk Assessment: Level of Observation" with an "X" in the box allocated for "Q15."

Review of the Day shift RN Assessment and Progress Note dated 03/12/2022 at 7:00 AM to7:00 PM showed " ...Q15 mins check continuous for safety ...."

Review of the "Patient Observation Sheet" dated 03/12/2022, showed the observation sheet lacked documentation to show the safety checks were completed for the following times: 2:30 PM, 2:45 PM, 3:00 PM, and 3:15 PM.

The surveyor conducted a face-to-face interview on 05/23/2022 at approximately 2:55 PM with Employee #3, Assistant Chief Nursing Officer. When queried who is responsible for making sure every 15 min (Q15) observations are complete, she stated "The nurses are responsible for making sure the Q15 min checks are complete." Additionally, she stated the nurses are aware it's their responsibility to ensure it's completed.

Based on medical record review, hospital policy review, and staff interviews, the nursing staff failed to document sexual victimization precautions per physician's orders on a patient's initial treatment plan in one of ten records reviewed (Patient # 2).

Findings Included ....

Review of the hospital policy titled, "Inpatient Documentation Requirements" revised June 2021 showed under "Nursing Staff Requirements ...Initial Treatment Plan for nursing care of each patient admitted to the hospital, to include both psychiatric and medical concerns. Master Treatment Plan ..Include nursing interventions necessary for the treatment of the patient.

Review of the medical record on 05/23/2022 at approximately 2:44 PM showed Patient #2 was admitted to the facility under FD-12 (involuntary emergency hospitalization) by the Metropolitan Police Department for mental health evaluation and treatment for bizarre behaviors and complaint of an alleged sexual assault on 04/14/2022. Patient #2 was admitted with diagnoses to include but not limited to Unspecified Schizophrenia Spectrum, and Other Psychotic Spectrum Disorder and has a history of anxiety, depression, and childhood trauma related to sexual abuse.

A physician's order dated 04/15/2022 at 1:00 PM showed "Precautions: Sexual Victimization Precaution." Further review showed staff selected "None" in the "Risk of Sexual Victimization" section on the Initial Nursing Treatment Plan. As a result, no specific intervention focus was initiated.

The surveyor conducted a face-to-face interview on 05/23/2022 at approximately 2:44 PM with Employee #3, Assistant Chief Nursing Officer in regards to the documentation of special precautions. Employee #3 stated, "If there is a physician's order for special precautions, it should be documented on the observation checklist and the initial treatment plan or master plan. The treatment plan and observation checklist should address sexual victimization precautions. There is a process in place to avoid gaps in documentation by having the night shift staff check the charts for orders and select special precautions for the day shift to assess."

Based on medical record review, hospital policy review, and staff interviews, the hospital staff failed to maintain accurate medical records in two of five medical records reviewed.


The findings included ....

Review of the hospital policy titled, "Analysis Procedure" dated September 2017 showed, "The Health Information Department shall receive and maintain the medical record within twenty-four (24) hours of discharge or the next working day. The medical record will be analyzed for deficiencies and made available to the medical/clinical staff for correction within three working days of receipt."

The surveyor reviewed the medical record on 05/26/2022 at approximately 9:30 AM of Patient #3, who was admitted to the facility on 02/14/2022 with a diagnosis of Alcohol Use Disorder, Severe. During the medical record review, a "Night Shift Assessment and Progress Note", labeled with another patient's name, medical record number, and date of birth was located in Patient #3's chart.

The surveyor reviewed the medical record on 05/26/2022 at approximately 10:00 AM of Patient #4, who was admitted to the facility on 02/20/2022 with diagnoses to include Suicidal Ideation and Auditory Hallucinations. During the medical record review, a "Group Progress Note" with another patient's name and medical record number was located in Patient #4's chart.

The surveyor conducted a face-to-face interview on 05/26/2022 at approximately 10:00 AM with Employee #7, Director of Quality Management, to review the discrepancies. Employee #7 referenced the medical record policy for accuracy and acknowledged the findings.

Based on hospital policy review, video footage review, and staff interviews, the hospital staff failed to don surgical masks for infection control and prevention in two of two observations.

Review of the hospital policy titled," Personal Protective Equipment (PPE)" dated April 2020 showed "Personal protective equipment (PPE) use is part of standard precautions for all health care workers to prevent skin and mucous membrane exposure when in contact with blood and body fluid of any patient. PPE includes protective laboratory clothing, disposable gowns, disposable gloves, eye protection, and face masks ...A mask shall be worn in any situation to prevent the spread of micro-organisms from the nasopharynx of staff of the patient to others who are susceptible ...Surgical mask: used in patient care units, hospital departments ..."

According to "Coronavirus 2019 (COVID-19): Guidance for PPE for healthcare Facilities and Alternative Care Settings" last revised on April 18, 2022, showed under the "Specific PPE Guidance" section " .... All HCP (Healthcare Personnel) must wear a respirator or procedural mask for source control while in the HFC (Health Care Facilities) ...."

A. Review of the video footage of Unit 4 dated, 04/21/2022 at 10:32:14 PM in the presence of Employee # 8, Interim Risk Manager, showed one employee walking in the hallway of Unit 4 into a patient's room with her surgical mask below her chin; employee's nose and mouth were uncovered.

The surveyor conducted a face-to-face interview with Employee #8 on 05/20/2022 at approximately 2:37 PM with regards to PPE. Employee # 8, stated, "All staff should wear surgical masks in patient care areas." An additional interview was conducted on 05/23/2022 at approximately 2:44 PM with Employee # 3, Assistant Chief Nursing Officer who stated, "PPE is a typical standard of patient care. All staff is aware of the required surgical masks, and we strongly recommend and mandate that they wear a mask for patient safety as well as staff."


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B. The surveyors conducted an observation of the facility's video surveillance footage on 05/20/2022 at approximately 2:37 PM with Employee #8, Interim Risk Manager. A review of the video footage dated 04/22/2022 at 11:23 AM showed Employee #30, Patient Advocate, in a patient care setting with the surgical mask pulled down below the chin engaging with Patient #2.

The surveyor conducted a face-to-face interview on 05/23/2022 at 2:44 PM with Employee #3, Assistant Chief Nursing Officer. When queried are all staff aware of mask requirements, she stated "All the staff are aware they should be wearing a surgical mask. This is definitely something we have to follow up with."