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This condition level deficiency is cited based on observations, review of medical records, the facility's Performance Improvement Plan for 2014, Quality Meeting Minutes, the facility's policies and procedures, CDC (Centers for Disease Control) safe practices, Infection Prevention Committee minutes, medication manufacturer storage recommendations, washing machine disinfection/dryer filter check log and interviews with facility staff, it was determined the Governing Body failed to ensure the hospital:

1. Maintained a safe environment for patient care.

2. Developed, implemented and maintained a quality assessment and performance improvement program.

3. Maintained the pharmacy under the direction of a registered pharmacist to ensure home medications were verified by the pharmacist, controlled substances were accounted for and medications/biologicals readily available for patient use were maintained according to facility policy and not expired.

4. Maintained an active infection control program to monitor, prevent and control infections.

5. Staff followed infection control policies to prevent potential infections.


This had the potential to negatively affect all patients served by this facility and all facility staff.


Refer to A0057 for additional findings.

Based on observations, review of the medical records, facility's Performance Improvement Plan for 2014, Quality Meeting Minutes, the facility's policies and procedures, CDC (Centers for Disease Control) safe practices, Infection Prevention Committee minutes, medication manufacturer storage recommendations, washing machine disinfection/dryer filter check log and interviews with facility staff, it was determined the Governing Body failed to ensure the hospital:

1. Maintained a safe environment for patient care.

2. Developed, implemented and maintained a quality assessment and performance improvement program.

3. Maintained the pharmacy under the direction of a registered pharmacist to ensure home medications were verified by the pharmacist, controlled substances were accounted for and medications/biologicals readily available for patient use were maintained according to facility policy and not expired.

4. Maintained an active infection control program to monitor, prevent and control infections.

5. Staff followed infection control policies to prevent potential infections.


This had the potential to negatively affect all patients served by this facility and all facility staff.


Refer to A 115, A286, A490 and A747 for additional findings.

Based on observations, review of the medical records and the facility's policies and procedures, and interview, it was determined the facility failed to ensure the staff:

1. Followed the facility policy for Assault/Homicide Precautions.

2. Followed the facility policy for Patient Safety on the Detox Unit.

3. Followed the facility policy for Suicide Assessment and Precautions.

4. Followed the facility policy for Restraint Use.

5. Removed any object accessible to patients that may cause harm to the patients.


This affected 3 of 3 psychiatric medical records reviewed for patient safety. This included Patient Identifier (PI) # 3, # 14 and # 19 and had the potential to negatively affect all patients served by this facility.

Refer to A 144 for additional findings.

Based on observations, review of the medical records and the facility's policies and procedures and interview, it was determined the facility failed to ensure the staff:

1. Followed the facility policy for Assault/Homicide Precautions.

2. Followed the facility policy for Patient Safety on Detox Unit.

3. Followed the facility policy for Suicide Assessment and Precautions.

4. Followed the facility policy for Restraint Use.

5. Removed any object accessible to patients that may cause harm to the patients.



This affected 3 of 3 psychiatric medical records review for patient safety. This included Patient Identifier (PI) # 3, # 14 and # 19 and had the potential to negatively affect all patients served by this facility.


Findings include:

Facility Policy: Patient Safety on Detox Unit

Purpose:

Patients on the Bullock County Hospital's Bradford Unit are considered medical patients who are being provided detox services. Bullock County Hospital will ensure the safety of these patients by providing a safe environment with frequent observations. Patients who appear to have psychotic behavior will be referred to the Gateway (Psychiatric) Unit.

Policy:

...Rooms will be kept clear of clutter with no items on floor that could become fall hazards. Electrical outlets will be plugged with plastic safety plugs to create a barrier between patients and electrical energy.

A tour of the Bradford Unit Day Room was conducted on 5/28/14 at 9:00 AM. There were 17 electrical outlets that were not covered with plastic safety plugs.

The Bradford Unit patient Room # 300 had 9 electrical outlets that were not covered with plastic safety plugs.

The Bradford Unit patient Room # 307 had 9 electrical outlets that were not covered with plastic safety plugs

An interview with Employee Indentifer (EI) # 2, Registered Nurse/Quality was conducted on 5/28/14 at 9:15 AM. EI # 2 verified the electrical outlets were not covered with plastic safety plugs as per policy.

A Tour of the Gateway Unit (Psychiatric Unit) was conducted on 5/28/14 at 8:30 AM. The surveyor observed a cord on the patients' telephone approximately 6 to 8 feet long. The surveyor asked EI # 3, Registered Nurse(RN)/Quality Manager (QM) for Gateway if this could be a potential hazard for the patients and the response was yes.

Observations of the 2 bath rooms on the unit revealed hand held showers with metal covered extension hose approximately 4 feet long. The surveyor asked EI # 3 if these could be considered a potential hazard for the patients and the response was yes.

An interview was conducted with EI # 12, Co-Administrator on 5/29/14 at 9:00 AM. EI # 12 stated the telephone cord and shower extension hoses had been removed from the unit.

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Facility Policy: Assault/Homicide Precautions

Policy # A.80

Assault/Homicide Precautions shall be initiated when a patient demonstrates assualtive behavior, verbalizes intent to assault or harm, or has a history of previous assualtive behaviors.

1. Initiation of Assault/Homicide Precautions

B. The decision to initiate Assault/Homicide Precautions shall be made by the physician or an RN (Registered Nurse) when it is deemed necessary.

C. Any member of the treatment team shall recommend that a patient be placed on Assault/Homicide Precautions when the need is recognized...

G. While a patient is under an order for Assault/Homicide Precautions, the staff shall directly and visually observe the patient every fifteen (15) minutes.

Facility Policy: Suicide Assessment and Precautions
Policy # S.60

Policy:
Staff observing potential suicide statements and behaviors...take measures to promote safety...

Procedure
1. Patients are screened...and potential for self-harm by physician and/or nurse reviewers...
6. The patient's treatment plan shall be modified to address the suicidal ideation/threat or attempt...."


Facility Policy: Restraint Use
(No Policy #)
Review/Revised Date(s) 10/12

Purpose:

" Bullock County Hospital strives to protect the rights and dignity of all patient at all times by seeking a restraint-free environment while emphasizing both the physical and emotional well being of all patients...Restraints or seclusion will not be used as a means of coercion, threat, punishment...

Policy:

...4. Face to Face Evaluation: A physical and behavioral assessment inclusive of a comprehensive review of the patient's condition...The evaluation must be conducted by a qualified practitioner within the scope of their practice.

7. Seclusion: Involuntary confinement of a person in a room or an area where the person is prevented from leaving...

C. Ordering and Face-to- Face Evaluation

5. An authorized Licensed Independent Practitioner (LIP) must provide a new order for each episode of restraint...Notification must be documented in the patient record...

8. The following guidelines regarding orders and evaluation are specific to Violent/Self-destructive Restraints:

When a restraint or seclusion is used for the management of violent and/or self-destructive behavior...the Registered Nurse immediately notifies the LIP...The LIP performs a face-to-face evaluation within 1 hour of initiation or restraint or seclusion and authenticates the verbal order, including date and time of authentication...

D. Patient Monitoring & Assessment:

Violent/Self-Destructive: Ongoing assessment and monitoring...at intervals no greater than every 15 minutes, the patient will be assessed and re-evaluated related to the discontinuation of...seclusion. Documentation for Restraints/Seclusion...completed on the Restraint/Seclusion form...

Violent/Self-Destructive Assessment Frequency & Content
Every hour (and as needed):
Mental status/Level of distress/Agitation
...Every 15 minutes:
Circulation
Respirations
Mental Status...

F. Documentation Requirements
The following documentation shall be included in the medical record:

4. The patient's response to the intervention(s) used...

5. Individual Assessments and reassessments..."

H. Competency of Staff

Direct care staff will receive training in behavioral de-escalation, application, removal, observation, assessment, and evaluation of the use of restraining devices or seclusion. Only staff members who are deemed competent to do so will initiate restraint and provide care/monitoring for these patients. If care is required by a staff member not authorized to remove, apply, or manage restraints, this role will be delegated to a competent individual.

1. PI # 14 was admitted to the facility on 2/6/14.

Review of the Emergency Department (ED) Record dated 2/6/14 revealed a history of present illness stating, "...Presents with Homicidal Ideations for 1 week. The onset is Acute. The symptoms are moderate."

Review of the ED Nursing Notes and Vital Signs dated 2/6/14 at 8:25 PM revealed, " pt (patient) escorted by ...Police Depart. (department) pt. known to officer, stated, "I am going to kill all of you". Pt states "I am bipolar and Homicidal."

Review of the ED documentation dated 2/6/14 at 9:50 PM revealed the patient was to be transferred to Gateway (psychiatric unit) and would be placed in a medical room until a psychiatric room was available.

Review of the Nurse Note dated 2/6/14 at 9:52 PM revealed the patient arrived on the floor.

Review of the 2/7/14 at 12:18 AM Behavioral Health (BH) Admission assessment documentation revealed the," Chief Complaint/Reason for Consult: homicidal with precipitating events reports described as wants to kill everyone and was referred by law enforcement. History of thoughts or attempts of homicide: says she/he is going to cut everyone's throat. Patient has homicidal ideation: wants to kill everyone. Elopement potential due to history of elopement. Patient has potential for violence towards others described as wants to harm self and family".

Review of the Nurse Note dated 2/7/14 at 8:15 AM revealed the patient was in the room standing near the door.

Review of the Nurse Note dated 2/7/14 at 8:40 AM revealed the patient was not in her/his room and the staff immediately searched for the patient. Administration and Police were notified. Pt was noted to have eloped from the facility.

There was no documentation of visual observation of the patient every 15 minutes while on the medical floor.

An interview was conducted with Employee Indentifer # 4, Director of Nursing (DON) on 6/4/14 at 8:15 AM. The surveyor asked what homicidal and elopement precautions were taken while the patient was on the medical floor. The response was there was no documentation that homicidal and elopement precautions were taken on the medical floor.

Review of the Nurse Note dated 2/7/14 at 10:01 AM revealed the patient was returned to the facility via Police. The patient was transferred immediately to Gateway.

Review of the BH Shift Assessment dated 2/7/14 at 10:00 AM revealed the patient's homicidal ideations described as wants to kill everyone and suicidal ideations were repetitive or persistent.

Review of the Physician's Order dated 2/7/14 at 3:31 PM revealed orders for Continuous q (every) 15 minute checks.

Review of the Physician's Order dated 2/7/14 at 3:32 PM and 5:24 PM revealed orders for Continuous Suicide Precautions.

Medical record review for 2/7/14 to 2/14/14 did not include documentation of continuous suicide precautions. The facility failed to include and document interventions to manage PI # 14's problem for potential harm to self/others.



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2. PI # 3 was admitted to Gateway on 5/16/14 with diagnosis including Bipolar Mood Disorder, Manic with Psychosis and Alcohol abuse.

Review of the 5/16/14 18:21 BH Admission assessment documentation revealed the reason for consult: "...Psychotic...Precipitating events... described as...Homicidal. Verbally aggressive and threatening towards law enforcement..." The patient's behavior was documented as "uncooperative".

Review of nursing orders dated 5/16/14 at 9:51 PM included continuous suicide precautions.

Review of the 5/16/14 11:11 PM Admission Suicide Assessment documentation revealed the patient is "unwilling" to disclose attempts of serious self harm. Documentation of dangerous ideations revealed the patient is "unwilling" to disclose any homicidal ideation or history or thoughts of homicide.

Review of the 5/16/14 11:36 PM Initial Treatment Plan revealed a master problem list for potential harm to self/others as characterized by thoughts of harming others.

The 5/16/14 Physician's Admission History and Physical (H & P) revealed the patient was at the facility by court order with aggressive threatening behavior to law enforcement. The physician's history documented the present illness to include "...delusional...difficult to redirect, uncooperative, impulsive with mood aggressive and agitated. The patient is homicidal...with intact cognition, poor insight and judgement..."

The 5/16/14 Physician's H& P summary included the following documentation: "The patient is placed on suicidal and homicidal precautions...Psycho-education and supportive psychotherapy will be provided..."

Review of the 5/17/14 12:50 PM nurse note documentation revealed PI # 3 " threatened to shoot (named individual) in the face. Will continue to monitor." The next documented entry for monitoring for homicidal ideations was 5/17/14 at 8:33 PM, greater than 7 hours. There was no documentation the was physician notified of PI # 3's homicidal threat.

Medical record review for 5/17/14, 5/18/14 and 5/19/14 failed to include documentation for continuous suicide precautions implementation. The facility failed to include interventions to manage PI # 3's problem for potential harm to self/others.

Review of the q 15 minute Observation Logs performed 5/17/14 to 5/27/14 did not include suicide precautions as an intervention.

Review of the 5/20/14 and 5/21/14 AM (morning) RN shift assessment documentation included q 15 minutes checks with homicide and suicide precautions. Review of the 5/20/14 and 5/21/14 Gateway Observation Logs revealed no documentation of instructions for monitoring for suicide or homicidal precautions observation.

Review of the 5/26/14 and 5/27/14 AM RN shift assessment documentation included q 15 minute checks with homicide, sexual acting out and suicide precautions. Review of the 5/26/14 and 5/27/14 Gateway Observation Logs revealed no documentation of instructions for monitoring for suicide or homicidal precautions observation.

An interview was conducted on 5/29/14 at 2:35 PM with EI # 10, Mental Health Counselor. EI # 10 validated the care documented failed to meet facility policy requirements and interventions were not documented to ensure the safety needs of staff, patient's and PI # 3.


3. PI # 19 was admitted to Gateway voluntarily on 5/15/14 with diagnosis including Schizoaffective Disorder, Depression and Cocaine Abuse.

Review of the 5/16/14 3:39 PM nursing orders included continuous q 15 minute checks and continuous suicide precautions.

On 5/17/14 at 2:50 PM, the nurse documentation revealed the following:

" ...ya'll might as well get a shot ready cause I'm gonna cut the fool...Ativan...Haldol...and Benadryl IM (intramuscular) given for increased agitation/threats... (in) seclusion at this time; door closed at 14:55 (2:55 PM). Dr...notified at 14:56 (2:56 PM)...15:45 (3:45 PM) pt noted to be asleep on floor in seclusion room, NAD (no acute distress) noted. Will continue to monitor pt...18:14 (6:14 PM). Door to seclusion room is now open; pt appears to be asleep; eyes closed, respiration with ease. Will continue to monitor...20:13 (8:13 PM)...resting on floor in time out room. awaken and escorted to room pt sluggish calm and cooperative at this time. Care ongoing..."

Review of the 5/17/14 Restraint and Seclusion Monitoring Sheet documentation initiated at 3:00 PM and ended at 6:00 PM did not include respiratory monitoring every 15 minutes between 3:15 PM and 6:00 PM. There was no circulatory monitoring documentation between 4:30 PM and 6:00 PM.

The facility failed to perform and document patient assessments while in seclusion as per policy.

Review of the Face-to Face document revealed the use of seclusion began 5/17/14 at 2:55 PM with the physician's verbal order received at 2:56 PM. There was a physician signature. There was no date or time documented to reveal when the LIP face-to-face assessment was completed. There was no documentation the physician performed the assessment within 1 hour of seclusion initiation.

Record review revealed nursing staff documented on 5/23/14 at 8:00 PM the patient became verbally abusive, threatening to staff, unable to be redirected and was escorted to the seclusion room by mental health tech. The physician was notified at 8:03 PM. Police were called, arrived at 8:15 PM, the patient was cooperative with police and received IM Geodon medication.

There was no 5/23/14 Restraint and Seclusion Monitoring Sheet documentation. There was no LIP Face-to Face documentation. There were no q 15 minute patient observations documented on the 5/23/14 Observation Log between 11:45 AM to 11:45 PM. Review of the Observation Log revealed no documentation of the patient's status for the 12 hour period.

At 9:39 AM on 5/24/14 the nurse documented " PT (patient) presented to the nurses station stated that his right hand was hurting...that he was punching on the glass with his fist...some swelling noted...grip writers hand with some discomfort...given...Tylenol...instructed to elevate...Care & observation continues".

There was no documentation of the above patient behavior "punching the glass" on 5/23/14.

Review of nursing documentation from 5/19/14 through 5/27/14 failed to include precautions for continuous suicide were ongoing. The Gateway Observation Logs documentation for q 15 minute checks from 5/16/14 to 5/25/14 revealed no documentation of instructions for observation monitoring for suicide precautions.

An interview with EI # 3, RN, Quality Manager (QM) for Gateway on 5/29/14 at 3:45 PM confirmed staff had not followed the facility seclusion policy. The documentation did not reveal staff followed orders for suicide precautions.

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A tour of the Gateway Unit was conducted on 5/28/14 at 8:45 AM with EI # 3. A Behavioral Health Technician (BHT) was sitting in the hallway observing patients. The surveyor asked if this BHT was CPI (Crisis Prevention Training) trained. EI # 3 stated there had been a big turn over in staff and some of the new employees had not completed the training. The surveyor then requested a list of Gateway staff who had completed the CPI Training.

On 5/28/14 at 2:00 PM, EI # 4, Director of Nurses (DON) submitted a list of 43 Gateway Employees which documented only 2 RNs and 3 BHTs had CPI training.

Review of the Gateway work schedules from 5/5/14 to 5/30/14 on the & AM to 7 PM shift revealed on the following days there were no CPI trained staff:

5/8/14, 5/9/14, 5/12/14, 5/13/14, 5/15/14, 5/17/14, 5/18/14, 5/19/14, 5/22/14, 5/23/14, 5/26/14, 5/27/14, 5/29/14 and 5/31/14.

On 5/28/14 at 2:30 PM, the surveyor requested the policy on the required training for CPI.

Review of the policy titled Crisis Prevention Training, dated 5/28/14 and approved by the Director of Nursing, Administrator, and Chief Executive Officer on 5/29/14 was submitted 5/29/14 at 10:00 AM. The policy read as follows:

Policy:

Employees of the Gateway Behavioral Unit will receive crisis prevention training.

Procedure:

Employees of the Gateway unit who do not have a current certification in Crisis Prevention (CPI) will be trained within 60 days of hire. Employees are required to keep their certification current.

Refer to the example # 3 for PI # 19 on the dates 5/17/14 and 5/23/14 for incidents that occurred without a CPI trained personnel present.

Based on the review of the facility's Performance Improvement Plan for 2014, Quality Meeting Minutes, and interview, it was determined the facility failed to:

1. Recognize care that could be improved.

2. Recommend resolutions for problems identified to include action plans.

3. Provide opportunities to improve care, safety and services.

This had the potential to negatively affect all patient served by this facility.


Refer to A283 for additional findings.

Based on the review of the facility's Performance Improvement Plan for 2014, Quality Meeting Minutes, and interview, it was determined the facility failed to:

1. Recognize care that could be improved.

2. Recommend resolutions for problems identified to include action plans.

3. Provide opportunities to improve care, safety and services.

This had the potential to negatively affect all patients served by this facility.


Findings include:

Facility Performance Improvement Plan 2014:

Bullock County Hospital's Performance Improvement Plan is designed to provide a systematic and organized program for the promotion of safe and effective patient care. Through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optimal achievements, with appropriate accountability assumed by the Governing Body, Medical Staff, Senior Administration and staff. The organization has the responsibility of designing, measuring, assessing, and improving its performance and patient safety.

The Performance Improvement plan will allow for the implementation of continuous quality improvement through the following:

The recognition that care can be improved through collaborative efforts between all departments and professions within the hospital...

Recommendations for resolutions of problems and opportunities to improve patient care, safety, and services...

Goals:

The goals of the program are as follows:

To improve patient care, safety, quality, and service by measuring, assessing, and improving those clinical and support processes that most affect patient outcomes.

To improve patient care process and to promote patient safety.

Quality Improvement Model:

Bullock County Hospital utilizes the PDCA (Plan, Do, Check, Action) Cycle as the model for continuing performance improvement. This approach to improving performance includes:

1. Recognizing an opportunity and planning a change,

2. Testing the change by carrying out a small-scale study;

3. Analyzing results and identifying what was learned;

4. Taking action based on what was learned and beginning the cycle again.

Review of the facility's 2014 Performance Indicators revealed a goal under patient safety for fall rate per 1000 patient days (inpatient) to be less then 2.0.

Review of the of the rates for fall rate per 1000 patient days (inpatient) for:

January 2014 = 6.48
February 2014 = 4.62
March 2014 = 6.62
April 2014 = 4.20

Review of the Incident reports for 2014 revealed the following:

January 2014 = 5 falls
February 2014 = 4 falls
March 2014 = 5 falls.

Review of the Quality Meeting Minutes dated April 8, 2014 revealed the following:

Summary:

Departments presented data for First Quarter (January, February, March):

Health Information Management - very large numbers, possible glitch with...(computer system) Improvement needed in this section.

Pharmacy - Improvement needed with expired meds (medications)...

Bradford - Improvement needed on Admission Med. Rec. (reconciliation)

Gateway - Missing data, assist with missing data...

Environment of Care - Improvement needed...

Patient Safety - Improvement needed on Fall Rate per 1000 patient days

Case Management - improvement needed on Observation and One Day stays

Next meeting scheduled for July 8, 2014 at 11:15 AM.

An interview was conducted with Employee Identifier (EI) # 2, Registered Nurse/Quality on 5/29/14 at 12:45 PM. The surveyor requested the action plans to improve the above areas where improvements were needed, including the high rate of falls. EI # 2 stated there was no action plan for any of the above identified problems, including the increased incidence of falls.


Refer to A454 and A491 for additional findings.

Based on review of the medical records, policies and procedures and interviews, it was determined the facility failed to ensure the nursing staff:

1. Obtained physician orders for wound care provided.

2. Followed the facility's policy for wound care

3. Performed observational monitoring according to the physician orders

4. Reported changes in patient condition

5. Monitored patient intake and output according to the facility's policy.

This affected 7 of 14 records reviewed including, Patient Identifier (PI) # 2, # 3, # 4, # 6, # 7, # 16 and # 19. This also had the potential to affect all patients admitted to this facility.



Findings include:

Facility Policy: Wound Care

Purpose:

To provide consistent wound care protocols to assess, maintain and promote skin integrity.

Procedure:

2. Wound Photography/Documentation

a. Obtain consent to photograph from patient...Photos will be made of all wounds on admit and day of discharge.

b. Documentation of existing wound will include photograph containing measurement reference (wound ruler) patient position and distance from wound, date and time...Wound measurement sticker should be placed adjacent to wounds with measurements written on sticker....

c. If more than one wound, number each photo and document on flow sheet, measure each wound (in centimeters) for length/width/depth...

Facility Policy:
Policy Title: Intake and Output
Revised date: 10/12

Policy:
It is the policy of Bullock County Hospital to accurately measure the total amount of fluids taken in and eliminated, by the patient, by all routes to determine fluid balance status and needs.

Assessment:
The nurse will assess the patient's:
a. Total intake, including oral liquids, IV (Intravenous) fluids, gastric lavage...


1. PI # 16 was admitted to the facility on 5/7/14 with a diagnosis of Fever, Unspecified.

Review of the Wound Care Treatment documentation dated 5/7/14 at 10:00 AM and 5/8/14 at 10:00 AM revealed the patient had 5 wounds described as follows:

Wound # 1 - open area to left inner buttocks with 10% eschar.

Wound # 2 - open area to right inner buttocks with red and white tissue.

Wound # 3 - open area to the left lower buttocks with yellow tissue.

Wound # 4 - open area to the right lower buttocks with white tissue

Wound # 5 - open area to left heel. Moderate amount of purulent drainage with foul odor.

Wounds # 1 - 4 were cleaned with Normal Saline (NS) and silvadene was applied.

Wound # 5 was cleaned with NS, dressed with Aquacel, cover with 4 x 4 gauze, wrapped with king and secured with tape.

There was no documentation of a photograph or wound measurements.

Review of the physician orders dated 5/8/14 at 9:00 PM revealed orders for the nursing staff to apply silvadene cream twice a day.

Review of the Wound Care Treatment notes for 5/9/14, 5/10/14, 5/11/14, 5/12/14 and 5/13/14 included the same documentation as on 5/7/14 and 5/8/14. There was no documentation of a photograph nor wound measurements during the patient's stay in this facility.

Review of the physician orders revealed no documentation of an order for Aquacel.

A written response to the surveyor's questions concerning physician orders for wound care, wound measurements and photographs of the patient's wound was submitted on 5/28/14 by Employee Indentifer (EI) # 4, Director of Nursing (DON) on 5/28/14. A review of the written response revealed there was no physician's order for silvadene until 5/8/14 at 9:00 PM, no physician's order for Aquacel and there was no documentation of a wound photograph or measurement.




30952

2. PI # 3 was admitted to Gateway on 5/16/14 with diagnoses including Bipolar Mood Disorder, Manic with Psychosis and Alcohol Abuse.

Record review revealed a 5/23/14 3:15 PM physician progress note that included the patient refused "...Depakote and is responding to treatment... can be likely discharged home next week if ... continues to cooperate...".

Review of documented patient behaviors on 5/24/14 at 8:12 AM included "using profanity, pulling shirt up, intrusive behaviors, pushing doors forcefully, will continue to monitor...". PI # 3 received Haldol, Ativan and Benadryl for the behaviors. At 11:26 AM, PI # 3's behavior was documented as belligerent and threatening toward staff. PI# 3 was medicated with "IM (intramuscular) cocktail." At 6:14 PM the nursing documentation revealed PI # 3 was "...confrontational and argumentative. Will continue to monitor."

Review of the 5/25/14 8:41 AM nursing documentation revealed PI # 3's behavior as argumentative, noted to be talking to self, appeared to experience audio hallucinations, grandiose behavior, was demanding and intrusive, dressed provocative and required redirection with attire.

Review of the 5/26/14 10:30 AM nurse documentation revealed PI # 3's behavior was hostile, angry, very unkept appearance, argumentative, noted to be talking to self, appeared to be experiencing audio hallucinations, grandiose behavior, was demanding and intrusive and required redirection with attire.

There was no documentation the physician was notified regarding lack of progress for 5/24/14, 5/25/14 or 5/26/14. There was no individual counseling or one to one documentation on the above dates.

Review of the medical record included nursing orders dated 5/16/14 at 9:15 PM for continuous q (every) 15 minute checks.

Review of the Gateway Observation Logs revealed the following documentation missing:

5/19/14: 10:47 PM-11:14 PM; no documented observations for 33 minutes
5/20/14: 2:46 AM-3:14 AM; no documented observations for 28 minutes
5/20/14: 4:47 AM-5:13 AM; no documented observations for 25 minutes
5/20/14: 7:15 AM-7:00 PM; no signature of staff who performed observations
5/21/14: 12:00 AM-5:45 AM-no signature of staff who performed observations
5/22/14: 12:49 AM-1:13 AM; no documented observations for 23 minutes
5/22/14: 4:48 AM-5:13 AM; no documented observations for 24 minutes
5/23/14: 7:46 PM-8:14 PM; no documented observations for 26 minutes
5/23/14: 10:46 PM-11:12 PM; no documented observations for 25 minutes
5/24/14: 12:49 AM-1:13 AM; no documented observations for 25 minutes
5/24/14: 2:47 AM-3:11 AM; no documented observations for 23 minutes
5/24/14: 4:48 AM-5:13 AM; no documented observations for 24 minutes
5/24/14: 6:47 AM-7:00 PM; no signature of staff who performed observations
5/25/14: 7:15 AM-7:00 PM: no signature of staff who performed observations
5/26/14: 12:52 AM-1:18 AM; no documented observations for 26 minutes
5/26/14: 1:48 AM-2:13 AM; no documented observations for 24 minutes
5/26/14: 4:48 AM-5:09 AM; no documented observations for 20 minutes
5/26/14: 2:15 PM-2:45 PM; no documented observations for 24 minutes
5/27/14: 5:15 PM-5:45 PM; no signature of staff who performed observations

There was no documentation staff notified the psychiatrist from 5/23/14 to 5/26/14 with declining behaviors observed or that individual counseling was provided.

An interview was conducted on 5/29/14 at 3:45 PM with EI # 3, Registered Nurse (RN), Quality Manager (QM) for Gateway who confirmed staff failed to follow the facility policy for q 15 minute observations and documentation.


3. PI # 7 was admitted to the medical unit 5/24/14 at 3:52 PM with diagnoses of Dehydration and Urinary Tract Infection. The patient was 6 weeks pregnant.

The 5/24/14 at 4:44 PM Physician order's included Sodium Chloride 0.9 % 1000 ml (milliliter) IV (intravenous) Q 9 hours at 100 ml/hour.

The 5/24/14 9:16 PM Physician order's included Intake and Output (I & O) monitoring q 12 hours.

Review of the 5/26/14 I & O documentation revealed no documentation of the patient's IV intake for 5/26/14 at 6:33 PM. Review of the I & O documentation dated 5/27/14 and 5/28/14 revealed no documentation of the patient's IV intake. PI # 7's IV was discontinued on 5/28/14 at 11:40 AM.

An interview with EI # 4 on 5/29/14 at 8:45 AM verified the above findings.


4. PI # 6 was admitted to Gateway on 5/23/14 with diagnoses including Schizoaffective disorder, Bipolar Manic and Cocaine Dependence. Review of the 5/23/14 Physician's Summary revealed PI # 6 was on the Bradford Unit for cocaine dependence, was having suicidal thoughts and was transferred to Gateway.

Review of the 5/23/14 9:57 PM Behavioral Health (BH) RN (Registered Nurse) Shift Assessment documentation revealed q 15 minute checks were ordered.

Review of the Gateway Observation Logs revealed the following missing documentation :

5/24/14: 7:15 am-11:45 PM: no signature of staff who performed observations
5/25/14: 7:15 am-7:00 PM: no signature of staff who performed observations

An interview at 2:29 PM on 5/29/14 with EI # 3 confirmed staff failed to document signatures on the observation logs.


5. PI # 19 was admitted to Gateway voluntarily on 5/15/14 with diagnoses including Schizoaffective Disorder, Depression and Cocaine Abuse.

The 5/16/14 Nurse Orders included q 15 minute checks and continuous suicide precautions.

Review of the Gateway Observation Logs revealed the following:

5/16/14: 8:15 PM-9:15 PM: no observations were documented for 60 minutes.
5/18/14: No Observation Log documentation in medical record for 24 hours
5/19/14: 7:15 AM-7:00 PM: no signature of staff who performed observations
5/20/14: 7:47 PM-8:13 PM; no documented observations for 25 minutes
5/21/14:12:49 AM-1:16 AM; no documented observations for 27 minutes
5/21/14: 5:48 AM-6:12 AM; no documented observations for 24 minutes
5/21/14: 4:44 AM-6:43 AM; no signature of staff who performed observations
5/24/14: 7:15 AM-7:00 PM; no signature of staff who performed observations
5/24/14: 7:44 PM-8:06 PM; no documented observations for 22 minutes
5/24/14: 8:53 PM-9:16 PM; no documented observations for 23 minutes
5/24/14: 9:48 PM-10:12 PM: no documented observations for 24 minutes

Suicide precautions were not documented on the Observation Logs.

Review of the Nurse documentation on 5/17/14 at 3:07 PM revealed the patient stated "y'all might as well get a shot ready cause I'm gonna cut the fool". Ativan, Haldol and Benadryl were administered and the patient was placed in seclusion with the "door closed at 14:55 (2:55 PM)". The physician was notified at 2:56 PM .

The 5/17/14 at 3:50 PM nurse documentation revealed the patient asleep on floor in seclusion room and will continue to monitor.

At 6:11 PM on 5/17/14 the nurse documentation revealed "door to seclusion room is now open. awake and escorted to room...sluggish calm and cooperative. Care ongoing."

Review of the 5/18/14 9:23 AM nurse documentation revealed "swelling noted hands due to punching door in seclusion room yesterday. Monitoring is ongoing with suicidal/homicidal precautions observed."

There was no documentation the physician was notified.

Review of the medical record revealed no documentation on 5/17/14 the patient was punching seclusion room door. Review of the 5/17/14 Observation Log revealed no documentation the patient was in the seclusion room at 2:55 PM until the nurse documented the patient was released to his/her room at 6:11 PM. Review of the 5/17/14 Observation Log documentation revealed the patient in the dayroom or smoking between 3:00 PM and 6:15 PM. This documentation was inconsistent with the nurse documentation, which revealed the patient was in seclusion from 2:55 PM to 6:11 PM.

There was no Observation Log dated 5/18/14 in the medical record.

Review of the 5/23/14 Observation Log revealed no documentation of observations of the patient after 11:45 AM.

Record review revealed 5/23/14 at 8:00 PM nurse documentation the patient became verbally abusive, was threatening staff, was unable to be redirected and was escorted to seclusion room by mental health tech. The physician was notified at 8:03 PM. Police were called and arrived at 8:15 PM at which time the documentation revealed the patient was cooperative with police and received Geodon IM.

There was no Restraint and Seclusion monitoring sheet documentation for 5/23/14.

Review of the 5/24/14 9:39 AM nurse documentation revealed the patient presented to nurses station reporting pain to right hand due to punching on the glass with his/her fist last night (5/23/14) and swelling was observed by nursing staff.

There was no documentation the physician was notified.

On 5/25/14 at 12:30 PM the nurse documentation revealed the patient was in the day room being "hyper-verbal and argumentative with staff and peers, provoking peers into verbal altercations. Need frequent redirection... Will continue to monitor". There were no documented interventions to prevent potential injury to patients and staff.

Review of the 5/26/14 6:50 PM nurse documentation revealed the patient was loud and verbally aggressive and required redirection and ongoing monitoring.

There were no documented counseling notes or one to one sessions between 5/19/14 and 5/26/14.

An interview on 5/29/14 at 3:35 PM with EI # 3 confirmed staff failed to observe, address, provide and document care to meet PI # 19's needs.




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6. PI # 2, a 4 year old patient was admitted to the facility on 5/26/14 with a diagnosis of Facial Abscess and Cellulitis. Review of the physician's order dated 5/26/14 at 6:55 AM revealed orders for continuous IV fluids of Normal Saline at the rate of 50 ml and to monitor the patient's I & O every 12 hours.

Review of the I and O record dated 5/26/14 - 5/27/14 revealed no documentation of the IV intake for the above dates.

An interview was conducted on 5/29/14 at 10:00 AM with EI # 4 who verified the staff failed to follow physician orders for monitoring I and O on the above patient as per facility policy.


7. PI # 4 was admitted to the Gateway Unit on 5/22/14 with the diagnosis of Bipolar Disorder. Review of the physician's orders dated 5/22/14 at 12:47 PM revealed orders for continuous q 15 minute checks and continuous suicide precautions.

Review of the Gateway Observation Logs revealed the following missing documentation:

5/22/14: Suicide Precautions were not documented.
7:00 AM - 8:00 AM; no observations documented for 60 minutes.

5/23/14: Suicide Precautions were not documented.
8:44 PM - 9:09 PM; no observations were documented for 23 minutes.
9:39 PM - 9:54 PM; no observations were documented for 25 minutes.
10:46 PM- 11:12 PM; no observations were documented for 26 minutes.

5/24/14 Suicide Precautions were not documented.
2:47 AM - 3:11 AM; no observations were documented for 24 minutes.
3:56 AM - 4:18 AM; no observations were documented for 22 minutes.
6:00 PM - 6:45 PM; no documented signature of staff performing the observations.

5/25/14 Suicide Precautions were not documented.
8:57 PM - 9:16 PM; no observations were documented for 18 minutes.

5/26/14 Suicide Precautions were not documented.
5/27/14 Suicide Precautions were not documented.

An interview was conducted on 5/29/14 at 10:00 AM with EI # 4, DON confirmed the above findings and staff failed to follow physician's orders for q 15 minute observations and documentation of suicide precautions.

Based on review of medical records, polices and procedures and interviews, it was determined the treatment team failed to follow their own policy for:

1. Multidisciplinary Treatment Plan

2. Individual note documentation

This affected 4 of 4 records reviewed for treatment plans. This affect Patient Identifer (PI) #s 3, # 6, # 14, and # 19 and had the potential to affect all patients served in this facility.


Findings include:

Facility Policy: Multidisciplinary Treatment Plan
Policy Number M.50

Purpose:

To provide individualized care response to the patient's specific need and to ensure the patient's participation in care is provided.

A. Each patient shall have a written individualized treatment plan based on the patient's present problems, physical health, emotional and behavioral status, strengths and weaknesses. The Multidisciplinary Team Plan shall be derived from each discipline's assessment of the patient as well as the patient/family perceptions of the patient's needs. This includes a review of the data available at the time of the information of the plan, to include:

1. Pre-screen Assessment

2. Psychiatric evaluation with emphasis on the physician's initial treatment plan.

3. All documentation from previous admissions or records requested/brought with the patient.

4. Nursing Assessment

5. Psychological History

6. Psychological Testing (if applicable)

7. Occupational Therapy Assessment (if available)

8. Activity Recreational Therapy Assessment (if applicable)

B. The plan of care is supervised by the attending psychiatrist. The Multidisciplinary Treatment Plan will be completed no later than three (3) days following the date of admission. The Multidisciplinary Treatment Plan shall be signed by the attending physician and the treatment team.

C. The treatment plan shall be a multidisciplinary effort based on the Multidisciplinary Treatment Team Assessment of the patient's clinical needs and will reflect the philosophy of the program. Each discipline is responsible for documenting his/her role and intervention. The RN (Registered Nurse) will incorporate the role of the physician in the plan, based on the physician's plan of care from the psychiatric assessment.

D. Each disciple adding to the treatment plan will identify its entry by dating and signing the plan.

E. The Multidisciplinary Treatment Plan process must include active participation by the patient or legal representative. Other persons may participate in the treatment planning process as appropriate (or legal representative's) signature.

F. The Multidisciplinary Treatment Plan must address the patient's primary problems (those necessitating admission), educational needs, medical problems, ADL's (Activities of Daily Living), Discharge Planning, patient strengths and weaknesses.

G. All problem statements shall contain three (3) components:
1) The problem itself
2) The specific symptoms or behaviors exhibited (evidenced by...)
3) The precipitating factors (related to...)

H. Short and long term goals for the problem identified shall be formulated. Objectives must be behavioral, measurable, realistic, time limited, and must be stated in positive terms. Goals must be patient goals.

I. Interventions must describe how they will assist the patient in meeting the objectives. The frequency of performance and length of the interventions must be documented. The person responsible, with his/her title for performing each intervention, must be documented.

J. Realistic Target date for patient's accomplishment of each goal must be established and documented.

K. If the objective/interventions require revision, documentation of a revision date must be included and the plan revised accordingly to reflect the revision.

L. When an objective has been accomplished, a resolution date must be documented.

M. The Multidisciplinary Treatment Plan shall be reviewed at least weekly by the treatment team.


Facility Policy: Documentation: Gateway Behavioral Health Unit
Policy Number D.80

Policy: Documentation by all Multidisciplinary Team Members in Gateway unit shall follow the electronic health record format.

1. Individual Note

A. Each discipline, whether nursing, case management or treatment modalities involved in the care and treatment of patients in the Gateway Unit shall document...Individual notes shall include at at minimum:
1) Behavior symptoms
(a) Explanation of what the patient did while in the particular session
2) Interventions
(a) content of the session
(b) Specific actions taken to assist the patient in meeting the objective identified
3) Patient Response to interventions
(a) Patient's level of understanding
(b) Patient insight
(c) Assessment of the patient's progress or lack of...
4) P=Plan
(a) what will be done in the next session
(b) Ongoing plans to assist the patient in meeting treatment goals...by the Plan of Care

B. The note shall also include...
2. Type of treatment modality guiding the session...
4. Treatment objective being addressed that corresponds to the content of the note...

III. General Documentation Guidelines for Paper Charting

A. Each entry shall be accurate, legible, written or printed..
B. Each entry shall be signed using the first initial, last name, and title of the person documenting...
E. Blank lines and spaces shall not be left following entries...
G. Documentation shall be objective and factual with clear and concise terms being used..."



1. PI # 14 was admitted to the facility on 2/6/14.

Review of the Emergency Department (ED) record dated 2/6/14 revealed a history of present illness stating, "...Presents with Homicidal Ideations for 1 week. The onset is Acute. The symptoms are moderate."

Review of the ED Nursing Notes and Vital Signs dated 2/6/14 at 8:25 PM revealed, "pt (patient) escorted by ...Police Depart. (department) pt. known to officer, stated, I am going to kill all of you. Pt states, I am bipolar and Homicidal."

Review of the Emergency Department documentation dated 2/6/14 at 9:50 PM revealed the patient was to be transferred to Gateway (psychiatric unit) and would be placed in a medical room until a psychiatric room was available.

Review of the Nurse Note dated 2/6/14 at 9:52 PM revealed the patient arrived to the floor.

Review of the Nurse Note dated 2/7/14 at 8:40 AM revealed the patient was not in her/his room and the staff immediately searched for the patient. Administration and the police were notified. The pt (patient) was noted to have eloped from the facility.

Review of the Nurse Note dated 2/7/14 at 10:01 AM revealed the patient was returned to the facility via the police. The patient was transferred immediately to Gateway.

Review of the Initial Treatment Plan dated 2/7/14 at 11:59 AM revealed the following:

1. Diagnosis of Mental Illness (Hallucinations and Delusions).

2. Problem 1: perception/cognitive disturbance as characterized by disorganized behavior, disorganized thoughts, hallucinations, and labile mood.

There was no documentation of the following:

1. The plan of care (POC) was supervised by the attending psychiatrist.

2. The entire Multidisciplinary Treatment Team took part in the development of the POC.

3. The patient/legal representative was included for an active participation.

4. The patient's homicidal ideations or elopement.

5. Of the precipitating factors.

6. Short or long term goals.

7. Interventions to assist the patient in meeting the objectives (goals).

8. Realistic target dates to meet the goals.

Review of the Adult SAD PERSON Scale (Suicidal Ideation scale) dated 2/7/14 at 12:03 PM revealed documentation the patient had no drug or alcohol abuse.

Review of the Team Meeting dated 2/7/14 at 5:27 PM revealed documentation the only members present were the nurse and the physician. Further review of the Team Meeting dated 2/7/14 at 5:27 PM revealed the reason for the patient's continued need for treatment was alcohol/drug abuse. There was no documentation of signatures of those who attended the meeting.

Review of the Team Meeting dated 2/10/14 at 12:31 PM revealed the patient's # 1 problem was substance abuse and substance abuse classes were needed. The patient's # 2 problem was perception/cognitive disturbance. The reasons for the patient's continued treatment were alcohol/drug abuse and medication monitoring. There was no documentation of signatures of those who attended the treatment plan meeting.

Review of the Team Meeting dated 2/12/14 at 4:48 PM revealed the patient's problem was perception/cognitive disturbance. The reasons for the patient's continued treatment were alcohol/drug abuse, lack of insight and medication monitoring. There was no documentation of signatures of those who attended the treatment plan meeting.




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2. PI # 3 was admitted to Gateway on 5/16/14 with diagnosis including Bipolar Mood Disorder, Manic with Psychosis and Alcohol abuse.

Review of the Registered Nurse (RN) Initial Treatment Plan dated 5/16/14 at 11:36 PM revealed a master problem list for potential harm to self/others as characterized by thoughts of harming others.

Review of the BH (Behavioral Health) Group Therapy Progress Note psycho education therapy documentation dated 5/17/14 at 10:44 AM revealed there was no participation by the patient. There was no plan documented for the care of the patient.

Review of the BH Group Therapy Progress Note psycho education therapy documentation dated 5/18/14 at 10:15 AM revealed there was no participation by the patient and the "patient was not in group". There was no plan documented for the care of the patient.

Review of the BH Group Therapy Progress Note psycho education therapy documentation dated 5/19/14 at 9:30 AM revealed there was minimal participation by the patient. There was no plan documentated for the care of the patient.

Review of the 5/19/14 at 2:34 PM Interdisciplinary Team Meeting (IDTM) revealed the following documentation: "...Master Problem List: Problem 1: ZYPREXA 10 mg (milligram) PO (by mouth) AT HS (at bedtime) ZYPREXA 5 MG PO DAILY. Treatment and Discharge Plan. Reasons for patient's continued need for treatment: medication monitoring. Referrals indicated: MAMHA (Montgomery Area Mental Health Association)..."

There were no documented individual counseling sessions between 5/17/14 and 5/19/14.

Review of the Counselor note documentation dated 5/20/14 at 10:22 AM revealed the following: "... Counselor will refer patient to psychiatrist for review of medications". Further review of the 5/20/14 counselor documentation revealed no documentation of the type of treatment modality guiding the session, a plan specific for the counselor's care, what would be done in the next session or specific ongoing plans to assist the patient in meeting treatment goals

Review of the 5/21/14 at 1:33 PM IDTM revealed the following documentation: "...Master Problem List: Problem 1: perception/cognitive disturbance Status: Progress as expected. Treatment and Discharge Plan. Reasons for patient's continued need for treatment: anxiety, hallucinations, irrational thoughts, lack of insight, medication monitoring and mood swings. Referrals indicated: MAMHA..."

The 5/19/14 and 5/21/14 IDTM's failed to include the following documentation as required by facility policy:

1. The plan of Care was supervised by the attending psychiatrist.
2. The entire Multidisciplinary Treatment Team took part in the development of the plan of care.
3. The patient/legal representative was included for an active participation.
4. The patient's homicidal ideations or elopement.
5. Of the precipitating factors.
6. Short or long term goals.
7. Interventions to assist the patient in meeting the objectives (goals).
8. Realistic target dates to meet the goals.

There was no documentation of signatures of those who attended the treatment plan meeting on 5/19/14 and 5/21/14.

Review of the BH Group Therapy Progress Notes dated 5/22/14 to 5/24/14 revealed the patient did not attend. There was no documented reason the patient did not participate. There was no documentation that one to one therapy sessions were performed. There was no plan documented for the care of the patient.

Review of the BH Group Therapy Progress Note dated 5/25/14 revealed PI's # 3 level of participation was minimal. There was no plan documented for the care of the patient. There was no documentation a one to one therapy session was performed 5/25/14.

Review of the RN shift assessment dated 5/26/14 at 11:18 AM included the following behaviors: argumentative, attention seeking, bizarre, dramatic, exhibitionistic verbally abusive acting out behavior and patient exposing (self) on 5/24/13.

Review of the BH Group Therapy Progress Note dated 5/27/14 revealed PI's # 3 level of participation was "no interaction". There was no plan documented for the care of the patient.

Review of the Counselor note documentation dated 5/27/14 at 3:12 PM included the following "...Patient is not stable...exhibit symptoms of psychosis...paranoia and delusions...Patient...not actively involved in treatment at this time. Counselor will continue to assess patient's mood, refer patient to psychiatrist for medication review ans (and) continue to provide ongoing supportive treatment". The counselor's documentation did not include the type of treatment modality guiding the 5/27/14 session, a plan to address the behaviors documented on 5/24/14 and 5/26/14 or a specific plan indicating what "ongoing supportive treatment" was to be provided in the next counselor's session.

Review of the Counselor note documentation dated 5/28/14 at 3:08 PM included the following: "...Patient attended Anger Management Group today...Patient was not actively involved or attentive during group...inappropriate by pulling her pants down. Patient constantly redirected...remains delusional...Counselor will continue supportive treatment". The 5/28/14 Counselor's documentation failed to include specific ongoing plans to assist the patient in meeting treatment objectives or goals.

An interview was performed on 5/29/14 at 2:50 PM with EI # 10, Mental Health Counselor, who validated the above.


3. PI # 6 was admitted to Gateway on 5/23/14 with diagnoses including Schizoaffective Disorder, Bipolar Manic and Cocaine Dependence. Review of the physician's summary dated 5/23/14 revealed PI # 6 was on the Bradford unit for cocaine dependence and was having suicidal thoughts.

Review of the Problems/Plan of Care revealed 39 documented Problems on the Plan of Care for PI # 6, some of which were dated 8/5/12. The surveyor was unable to determine PI # 6's current medical and psychiatric problems.

Review of the 5/23/14 5:40 PM BH RN Admission Assessment revealed a suicide risk assessment positive for 6 identified risk factors.

Review of the 5/23/14 5:12 PM BH Initial Treatment Plan revealed the following documentation: "Evaluator's Impression: Per report: Suicidal thoughts...Master Problem List: Problem 1: potential harm to self/others as characterized by periods of helplessness...hopelessness, and suicidal ideation with plan..."

Review of the 5/23/14 Adult SAD Scale documentation revealed PI # 6 was medium risk, interventions implemented.

Review of the 5/23/14 10:57 PM RN Shift assessment documentation revealed the following: "...Precautions and Restrictions...No precautions or restrictions required at this time."

Review of the 5/24/14 10:18 AM RN Shift assessment documentation revealed the following: "...Precautions and Restrictions-Level of observation; Q (every) 15 (minutes) checks... No precautions or restrictions required at this time."

Review of the BH Group Therapy Progress Notes dated 5/24/14 at 10:44 AM and 5/25/14 at 10:08 AM revealed the patient denied substance abuse. There was no documented plan for the care of the patient as per facility policy.

Review of the 5/25/14 10:08 AM RN Shift assessment documentation revealed the following: "Disoriented to situation...Mood is anxious and labile, behavior is hyperactive, and restless, thought content circumstantial and disorganized...Precautions and Restrictions-Level of observation; Q 15 checks... No precautions or restrictions required at this time."

There was no documentation one to one sessions or counseling therapies had been conducted since the 5/23/14 admission.

Review of the 5/26/14 10:13 AM RN Shift assessment documentation revealed the following: "...Precautions and Restrictions-Level of observation; Q 15 checks...No precautions or restrictions required at this time."

On 5/26/14 at 11:24 AM the Counselor documented in the psychosocial assessment "Patient presents with suicidal thoughts...experiencing feelings agitation, anxiety, feelings of worthlessness and mood swings." There was no documentation suicide precautions were implemented on 5/26/14.

There was no documented 5/26/14 Group Therapy interventions.

The 5/26/14 11:38 PM RN shift assessment documentation revealed patient precautions were falls and seizure. There was no documentation for suicide precautions.

Review of the 5/27/14 at 10:08 AM BH Group Therapy Progress Note psycho education therapy documentation revealed the patient denies substance abuse. There was no plan documented for the care of the patient.

The 5/27/14 9:58 AM RN shift assessment documentation revealed no patient precautions or restrictions were required at this time. There was no documentation suicide precautions had been implemented.

Review of the 5/27/14 at 10:00 AM BH Group Therapy Progress Note psycho education therapy documentation revealed the patient's mood was anxious and depressed and denies substance abuse. There was no plan documented for the care of the patient.

The 5/28/14 7:39 AM RN shift assessment documentation revealed no precautions or restrictions were required at this time. There was no documentation the facility implemented suicide precautions.

Review of the 5/28/14 3:46 PM IDTM revealed the following documentation: "...Master Problem List: Problem 1: perception/cognitive disturbance Status: Progress as expected. Treatment and Discharge Plan. Reasons for patient's continued need for treatment: feelings of hopelessness, medication monitoring, noncompliance with medications, and racing thoughts. Long Term Goal(s) Treatment for drug abuse..."

There were 38 of the 39 problems identified on the Problem List/ Plan of Care not addressed on the 5/28/14 IDTM.

The 5/28/14 IDTM failed to include the following documentation as required by facility policy:

1. The plan of Care was supervised by the attending psychiatrist.
2. The entire Multidisciplinary Treatment Team took part in the development of the plan of care.
3. The patient/legal representative was included for an active participation.
4. The patient's homicidal ideations or elopement.
5. Of the precipitating factors.
6. Short term goals.
7. Interventions to assist the patient in meeting the objectives (goals)
8. Realistic target dates to meet the goals.

There was no documentation of signatures of those who attended the 5/28/14 treatment plan meeting.

Review of the Counselor Individual Patient note documentation dated 5/28/14 at 10:33 AM included the following: "...Counselor will continue ongoing supportive treatment". The 5/28/14 Counselor's documentation failed to contain a plan specific for the counselor's care, what would be done in the next session or specific ongoing plans to assist the patient in meeting treatment goals.

Review of the medical record from 5/23/14 to 5/28/14 revealed no documentation suicide precautions were implemented. Review of the 5/24/14 to 5/27/14 Gateway Observation Log documentation revealed no instructions for suicide precautions.

An interview on 5/29/14 at 1:52 PM with EI # 3, Registered Nurse, Quality Manager for Gateway confirmed staff failed to identify, document and manage patient problems, complete IDTM and individual note documentation per policy.


4. PI # 19 was admitted to Gateway voluntarily on 5/15/14 with diagnosis including Schizoaffective Disorder, Depression and Cocaine Abuse.

Review of the Problems/Plan of Care for PI # 19 revealed 20 problems were documented, some of which were dated 1/19/2012. The surveyor was unable to determine PI # 19's current medical and psychiatric problems.

The 5/16/14 Nursing Orders included continuous q 15 minute checks and continuous suicide precautions. The Adult SAD PERSON Scale revealed the patient was medium risk and interventions were implemented.

Review of the 5/16/14 Individual Patient Counseling note documentation revealed the patient had suicidal ideations with a plan to jump off a bridge.

Review of the 5/16/14 10:00 AM BH Group Therapy Progress Note psycho education therapy documentation revealed the patient denies substance abuse. There was no plan documented for the care of the patient.

Review of the 5/16/14 1:00 PM IDTM revealed the following documentation: "...Master Problem List: Problem 1: perception/cognitive disturbance Risperadol 1 mg (milligram) po (by mouth) q hs (bedtime). D/C Geodon. Problem 2: substance abuse Bradford classes. Treatment and Discharge Plan. Reasons for patient's continued need for treatment: irritability, lack of insight and medication monitoring. Referrals indicated: walk-in".

Review of the 5/16/14 IDTM failed to include the following documentation as required by facility policy:

1. The plan of Care was supervised by the attending psychiatrist.
2. The entire Multidisciplinary Treatment Team took part in the development of the plan of care.
3. The patient/legal representative was included for an active participation.
4. The patient's homicidal ideations or elopement.
5. Of the precipitating factors.
6. Short term goals.
7. Realistic target dates to meet the goals.

There was no documentation of signatures of those who attended the 5/16/14 treatment plan meeting.

Record review revealed the patient checked himself/herself out of the Gateway Unit 5/17/14 at 10:40 AM against medical advice and was brought back to Gateway under court order (involuntary) at 3:07 PM by the police in hand/leg shackles.

Review of the 5/19/14 3:40 PM IDTM revealed the following documentation: "...Master Problem List: Problem 1:INVEGA SUSTENA 234 MG (milligram) IM (intramuscular) TODAY DOUBLE PORTIONS AT MEALS...Treatment and Discharge Plan. Reasons for patient's continued need for treatment: medication monitoring, Referrals Indicated: walk-in..."

Review of the 5/19/14 IDTM documentation failed to include the following as required by facility policy:

1. The plan of Care was supervised by the attending psychiatrist.
2. The entire Multidisciplinary Treatment Team took part in the development of the plan of care.
3. The patient/legal representative was included for an active participation.
4. The patient's homicidal ideations or elopement.
5. Of the precipitating factors.
6. Short or long term goals.
7. Interventions to assist the patient in meeting the objectives
8. Realistic target dates to meet the goals.

There was no documentation of signatures of those who attended the 5/19/14 treatment plan meeting.

The 20 of 20 identified problems on the Plan of Care were not addressed at the 5/19/14 IDTM.

Review of the 5/20/14 10:00 PM RN shift assessment documentation revealed the patient's behavior was argumentative, exhibitionistic and disoriented to situation.

Review of the 5/21/14 IDTM documentation included the following: "...Estimated LOS (length of stay): 7 days...Problem 1: affective disturbances Status: Progress as expected: Treatment and Discharge Plan
Reasons for patient's continued need for treatment: lack of insight, medication monitoring, and mood swings. Referrals indicated: walk-ins..."

Review of the 5/21/14 IDTM documentation failed to include the following as required by facility policy:

1. The plan of Care was supervised by the attending psychiatrist.
2. The entire Multidisciplinary Treatment Team took part in the development of the plan of care.
3. The patient/legal representative was included for an active participation.
4. The patient's homicidal ideations or elopement.
5. Of the precipitating factors.
6. Short or long term goals.
7. Interventions to assist the patient in meeting the objectives (goals)

There was no documentation of signatures of those who attended the 5/21/14 treatment plan meeting.

Review of the 5/22/14 10:00 AM BH Group Therapy Progress Note psycho education therapy documentation revealed the patient's participation was minimal and denies substance abuse. There was no plan documented for the care of the patient.

Review of the 5/23/14 10:00 AM BH Group Therapy Progress Note psycho education therapy documentation revealed the patient did not attend group and denies substance abuse. There was no documented plan for the care of the patient. There was no one to one or individual counseling session documentation for PI # 19 on 5/22/14 or 5/23/14.

An interview with EI # 3 on 5/29/14 at 3:35 PM revealed staff failed to plan, provide and document care according to the IDTM and individual note policy requirements.

Based on review of facility policy and procedure and interview with administrative staff, it was determined the hospital failed to ensure all verbal orders were dated, timed, and authenticated according to the facility's policy.

Findings include:

Facility Policy:
Subject: Verbal Orders
Revised date: 11/12

Policy:
It is the policy of Bullock County Hospital to use verbal orders infrequently and only when it is impossible or impractical for the ordering practitioner to enter the order into the EMR (Electronic Medical Record) without delaying treatment.

Procedure:
4. The responsible physician shall authenticate and date any order as soon as possible, such as during the next patient visit, and in no case longer than 48 hours.


A tour of the Medical Records Department was conducted on 5/28/14 at 9:40 AM with EI (Employee Identifier) # 13, Medical Record Manager. The surveyor asked for a percentage of records/orders that have not been completed within 30 days of discharge. EI # 13 was unable to compute the percentage as requested, but stated, "We have 5,545 incomplete records/orders and more than 400 over 30 days."

In an interview with EI # 13 on 5/29/14 at 9:15 AM, who stated, "We have a computer glitch, some of these records are complete."

Based on review of Emergency Department (ED) Medical Records (MR's), facility policy and procedure and staff interview, it was determined that the facility failed follow its policy to ensure the Authorization for Treatment form was properly signed in 5 of 20 MR's reviewed.

This affected ED Identifiers # 3, # 5, # 6, # 16, and # 17, and had the potential to negatively affect all patients served in the ED.

Findings include:

Policy/Procedure Title: Authorization to Treat
Effective Date: 3/13

Policy:
Consent for life-threatening emergencies for an adult and/or a minor is implied. Consent for treatment of non-life threatening visits shall be obtained for all patients.

Procedure:
The Authorization for Treatment shall be completed before treatment is begun, and the form shall be included in the medical record...

If the patient is competent and able to verbalize consent, but is unable to sign a consent form due to impaired vision, physical impairments, or illiteracy, staff will write the words "Patient Unable to Sign" and document the reason for the inability to sign on the consent form. A family member or other staff member will sign the form as a witness...

1. ED Identifier # 3 was admitted to the ED on 5/23/14 at 12:27 PM with the diagnosis of Head Trauma.

The consent form was signed by a corrections officer in the space titled "Patient." There was no documentation of an explanation as to why the patient was unable to sign. There was no documentation of the Relationship to the Patient.

2. ED Identifier # 5 was admitted to the ED on 5/12/14 at 2:04 AM with the diagnosis of Epigastric Pain.

The Authorization for Treatment form was signed, "Unable to sign (E.S.)" in the space for the patient to sign. There was no explanation as to why the patient was unable to sign. There was no documentation to define "E.S." There was no documentation of the Relationship to the Patient.

3. ED Identifier # 6 was admitted to the ED on 4/25/14 at 2:05 PM with the diagnosis of Bizarre Behavior.

In the space for the patient to sign the Authorization for Treatment form was found the initials "SO." There was no explanation as to why the patient was unable to sign and no documentation of the definition of "SO." There was also no documentation of the Relationship to the Patient.

4. ED Identifier # 16 was admitted to the ED on 2/15/14 at 5:46 PM with the diagnosis of Ingestion of Coins.

The Authorization for Treatment form was signed by an unknown person in the "Guarantor" section, and the "Relationship to Patient" section was blank with no explanation of to whom this signature belonged.

5. ED Identifier #17 was admitted to the ED on 2/7/14 at 5:30 with the diagnosis of Dog Bite.

On 5/29/14 at 7:30 AM request was made for a copy of the Authorization for Treatment, but none was provided.

An interview conducted on 5/29/14 at 9:30 AM with EI # 12, Administrator, confirmed the forms were not completed per policy. EI # 12 also stated during this interview the person who signed ED Identifier # 16's Authorization for Treatment form was the patient's mother.

This condition level deficiency is cited based on review of the facility policies and procedures, CDC (Centers for Disease Control) safe practices for use of multi-dose vials observations, and interviews, it was determined the facility failed to ensure:


1. Staff stored, dispensed, and managed medications according to the facility policy. Refer to A 491.

2. The facility had an active Director of Pharmacy. Refer to A 492.

3. The facility policy was followed for accounting of controlled substances. Refer to A 494.

4. All medications and biologicals available for patients were not expired. Refer to A 505.

5. All multi-dose vials were labeled according to the facility's policy. Refer to A 505.

Refer to A 491, A 492, A 494 and A 505 for additional findings.

This had the potential to negatively affect all patient served by the facility.

Based on review of facility policies, observations and interviews, it was determined the staff failed to store, dispense, and manage medications according to the facility policy. This had the potential to negatively affect all patient's served by this facility.

Findings include:

Facility Policy:
Subject: Patient Personal Medications
Date Revised: 12/13

Policy: It is the policy of Bullock County Hospital to keep track of all medications presented to nursing staff upon admission to the hospital.

Procedure:
1. Nursing staff will ask patient for all home medications upon arrival to the unit.

2. If patient's medications are to remain in the hospital, the following procedure should be put into place to safeguard patient's home medications. All home medications will be documentated on the security bag, all medications will be counted, by 2 nurses, and the number of each medication on hand will be documented on the security bag...

4. Patient's personal medications are not to be used in the hospital, unless specifically ordered by the physician, or if the medication is not stocked in the Pharmacy. Under both circumstances there must be an order in the patient record from the attending physician, which includes the patient name, name of med, dosage or strength, frequency... All home medications must be verified and documented as so in the patient's medical record by the hospital pharmacist if the patient will be taking them during hospitalization.

Facility Policy
Subject: Preparation and Administration of Drugs
Revised date: 12/12

Policy:
It is the policy of Bullock County Hospital to ensure that medications are prepared and administer by or under the supervision of licensed nurses or other licensed personnel to comply with federal and state laws.

Procedure:
5. The pharmacist shall be responsible for the following:
a. Determining the authenticity and appropriateness of the medication order before dispensing.
b. Selecting auxiliary labels and /or cautionary statements.
c. Monitoring patient profiles, if available for detection of inappropriate drug therapy.
d. Final check on all aspects of completed prescription.


An observation was made on 5/28/14 at 2:05 PM on the Bradford Unit. The following home medications were found in the medication cart in the patients individual drawers:
Room 301 A Combivent Inhaler.
Room 303 A Protopic ointment (apply daily per label from drug store)
Room 303 C Vascepa 1 Gram (2 capsules twice a day by mouth per label from drug store) and Pramipexole 0.25 mg (1 by mouth three times a day as stated of label from drug store)
Room 304 C Doxycycline 100 mg (milligram) (1 capsule twice a day as stated on label from drug store)
Acetaminophen 500 mg OTC (Over the counter).

There was no documentation the pharmacy/physician had verified the patient's home medications

EI # 18, RN (Registered Nurse) Staff Nurse was unable to communicate the policy regarding home medication or produce the form used for home medication reconciliation with pharmacy.

Based on observations, interviews and review of facility policies it was determined the facility failed to have an active Director of Pharmacy.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy:
Subject: Approval and Review of Policy and Procedure Manual
Date reviewed or revised: 4/14

Policy:
It is the policy of Bullock County Hospital that the policies contained in this manual shall be approved by the Medical Staff. The Director of Pharmacy shall review the Manual annually for necessary revisions.

Procedure:
1. The Chief of Medical Staff shall approve all new policies and procedures.

2. The Director of Pharmacy will review all policies and procedures annually for necessary revisions. Each policy will be signed by the Director of Pharmacy.

3. Record of Reviews and Record of Approvals will be filed at the beginning of the manual.

Review of the pharmacy policy and procedure manual revealed no documentation that the policies were reviewed by the Director of Pharmacy since November 2012.

An interview was conducted with Employee Identifier (EI) # 5, Pharmacist on 5/28/14 at 1:15 PM. EI # 5 verified the policies were not reviewed by the Director of Pharmacy annually. Surveyor asked EI # 5 if he was the Director of Pharmacy. The reply was, "I am not." EI # 5 was asked if there was another pharmacist by the facility, and the response was, "I am the only pharmacist." The surveyor asked are you responsible for the development, supervision, and coordination of pharmacy activities. The response was, "No".

An interview with EI # 12, Co-Administrator and EI # 2, Director of Nursing (DON) was conducted on 5/28/14 at 1:45 PM. EI # 12 was asked who the Director of Pharmacy was EI # 5 was identifier.

During the above mentioned interview EI # 5 and EI # 19 Chief Executive Officer entered the room where the surveyors were reviewing documents. EI # 5 was asked by the surveyor, if he was the Director of Pharmacy, to which his response was, "No". The administrative staff then left the interview.

EI # 12 returned on 5/28/14 at 3:35 PM and stated that EI # 5 has decided to spend more time with his family. Another pharmacist (EI # 20) has accepted the role as Interim Director of Pharmacy until we have a permanent replacement.

An interview was conducted with EI # 12 and EI # 20 on 5/29/14 at 8:50 AM and introduced EI # 20 as the new Interim Director of Pharmacy.

Based on observation and review of facility policy it was determined that the facility failed to follow the policy for accounting for controlled substances. This had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy:
Subject: Controlled Substances
Revised date: 11/13

Policy:
It is the policy of Bullock County Hospital to ensure that strict control will be maintained on all controlled substances. This requires compliance with the following procedures in a joint effort by the nursing staff and Pharmacy Staff.

5. Controlled drugs are to be accounted for each shift change, by nurse going off and nurse coming on duty. The DON (Director of Nurses) will devise the sheet for narcotic count to be done each shift by the nurse on each unit.


An observation was conducted in the Pharmacy Department on 5/27/14 at 1:45 PM with Employee Identifier (EI) # 6, Pharmacy Manager. The surveyor requested the daily narcotic shift count sheets for controlled substances as described in the policy. EI # 6 stated the requested narcotic shift count sheets had not been devised to date.

Based on observation, review of CDC (Centers for Disease Control) safe practices for use of multi-dose vials, facility policy and procedures and interview with staff it was determined the facility failed to ensure:

1. All medications and biologicals available for patients were not expired.

2. All multi-dose vials were labeled with the date opened.

This had the potential to negatively affect all patients served by this facility.


Findings include:

CDC- Multi-dose vials- Safe Practices last updated 2/9/11

Questions about multi-dose vials:

4. When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.

In addition, the United States Pharmacopoeia (USP) General Chapter 797[16] recommends the following for multi-dose vials of sterile pharmaceuticals:
1. If a multi-dose has been opened or accessed (needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Facility Policy:
Subject: Dating of Open Containers
Revised date: 10/12

Policy:
It is the policy of Bullock County Hospital to ensure that Nursing Staff/Pharmacy Staff, depending on the location of the drug, date all Multi Dose sealed containers upon opening, so that the risks of infection and diminished potency of substances can be controlled. If the multi dose medication seal is broken in the pharmacy, then the pharmacy staff will be responsible for dating the item. If the seal is broken on one of the units, then the nursing staff is responsible for dating the item. Single does vials should be discarded immediately after use. All open containers should be discarded within 28 days, after initial opening.

Procedure:
1. All multi dose medications, or other substances used in patient care regimens shall be dated upon opening. When the seal is broken, the staff person shall mark the open container as follows: MM-DD-YY (Month-Date-Year) followed by the persons initials.
2. All dated open containers should be checked periodically by staff members for dates. The open container should be returned to Pharmacy for destruction after 28 days from opening date.

An observation was conducted in the Pharmacy Department on 5/27/2014 at 1:45 PM. The surveyor observed the following expired medications:

Questran Powder 16 once (oz) (multi-dose container) which was open with no date and an expiration date of 4/14
20 Donnatel Elixir 5 milliliter (ml) 10 milligram (mg) expiration date of 4/14.
GI (Gastrointestinal) Cocktail 30 ml container expiration date of 5/25/14.

The following multi-dose medications were opened and not dated:
Bismatrol 4 oz (ounce) bottle
3 GI Cocktail 12 oz bottles
Metocloprramide 16 oz bottle
Dechlor DM 16 oz bottle
Hydroxyzine 4 oz bottle
Adult Robitussin 4 oz bottle
2 Nitropaste cream
Triamcinolone Acetonide cream 0.1%
Nystatin cream

The above findings were verified with Employee Identifier (EI) # 6, Pharmacy Manager on 5/27/14 at 2:10 PM.

During a tour conducted on the Bradford Unit on 5/28/14 at 2:30 PM the following medications were observed open with no date:
Humulin N Insulin 10 ml (milliliter) vial
Novolin R Insulin 10 ml vial
Levimir Insulin 10 ml vial with date of 4/11/14, opened greater than 28 days.

An observation of Omnicell refrigerator on Medical Surgical Unit was made on 5/28/14 at 2:45 PM and revealed the following opened, unlabeled or expired medications:
Novolin N Insulin 10 ml vial date opened 4/10/14, greater than 28 days.
Influenza vaccine 5 ml vial date opened 11/14/13, greater than 28 days.

EI # 2, Registered Nurse (RN) /Director of Quality was present during observation and verified the above findings.



30952

A tour of the outpatient lab was conducted on 5/27/14 at 10:50 AM. The surveyor observed one 10 ml bottle of sterile saline, which was open and not dated.

An interview was conducted on 5/27/14 at 10:55 AM with EI # 7, Lab Manager. EI # 7 verified the undated open saline bottle and discarded.

A tour of the Gateway unit was conducted on 5/27/14 at 1:50 PM. The following observations were made:
Lantus insulin 100 units/ml 10 ml, 1 vial open and not dated.
Tuberculin Purified Protein Derivative 1 vial, open dated 8/28/13, which was greater than 28 days.

An interview performed 5/27/14 at 1:55 PM with EI # 3, RN, Quality Manager (QM) at Gateway, confirmed the findings.




34108

A tour of the Emergency Department (ED) Room 2 was conducted on 5/27/14 at 11:30 AM. Located on the crash cart in this room, the surveyor found one 1,000 ml bag of D5W (5% dextrose in 1,000 ml sterile water) which expired on 3/14.

An interview was conducted with EI # 16, ED Staff Registered Nurse, on 5/27/14 at 11:45 AM, who verified the above findings.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...


During a tour of the Dietary Department on 5/27/14 at 11:30 AM with the EI # 11, Dietary Manager the surveyor observed opened food containers with no dates, food items which had expired and inappropriately stored food items.

Located in the cooler were the following inappropriately stored food items which were opened with no date:

2 pans of raw bacon covered with aluminum foil thawing on the middle shelf and located underneath was a container of butter packets.

Also located in the cooler were the following food items which were opened with no date:

A gallon container of Italian Salad Dressing
A gallon container of Mayonnaise
A gallon container of Pickle Relish
A 32 ounce (oz) container of Lemon juice
A box of heat and serve rolls
A box of hot dog buns
A box of lemons
A gallon container of BBQ Sauce
A gallon container of Pickle Relish
A gallon container of Dill Pickles
A gallon container of French Salad Dressing

Located in the freezer were the following food items which were opened with no date:

A bag of walnuts
A bag of coconut
A plastic wrapped package of ham
A bag of Okra

Dry Storage:
A bag of pancake flour
A bag of pasta

Ice Cream Freezer:
(2) 5 gallon containers of ice cream
(2) boxes of individual wrapper ice cream sandwiches

The following items were noted in the coolers that were dated, but expired:

(3) 32 oz containers of sour cream expired 11/13
(2) 32 oz containers of sour cream expired 10/13
A gallon container of 1000 Island Salad Dressing 2/23/11
A gallon container of cooked apples 3/11/14
2 pitchers of tea covered with plastic wrap 5/11/14
2 gallon containers of tea 5/24/14
3 gallon containers of tea 5/20/14

An interview was conducted on 5/27/14 at 11:55 AM with EI # 11, who confirmed the items listed above were expired, inappropriately stored, and were opened and not dated.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

This condition level deficiency is cited based on review of the facility's policies and procedures, Infection Prevention Committee minutes, medication manufacturer storage recommendations, washing machine disinfection/dryer filter check log, observations and staff interviews, it was determined the facility failed to ensure:

1. The Infection Prevention Surveillance policy was followed. Refer to A 748

2. The Infection Prevention Committee followed their own policy. Refer to A 748

3. Employees were screened annually with a tuberculin (TB) skin test, per policy. Refer to A 749

4. Staff followed the facility's policy for reporting animal bites. Refer to A 749

5. Staff followed the facility's policy for washer disinfection and dryer lint filter cleaning. Refer to A 749

6. Staff performed hand hygiene after blood glucose testing and following glove change. Refer to A 749

7. Ensure daily monitoring of medication refrigerator temperatures and freezers were defrosted when needed. Refer to A 749

Refer to A 748 and A 749 for additional findings.

This had the potential to negatively affect all patients served by this facility and all facility staff.

Based on review of the facility's policies and procedures and Infection Prevention Committee minutes and staff interview, it was determined the facility failed to ensure:

1. The Infection Preventionist (ICP) conducted surveillance of infections among patients and employees.

2. The Infection Prevention Committee followed their own policy to investigate, control, and prevent infections.


This had the potential to affect all patients served by this facility and all facility staff.


Findings include:

Facility Policy: Infection Prevention Surveillance

Purpose:

To conduct surveillance of healthcare-associated infections (HAI) to guide prevention activities.

Policy:

The ICP conduct surveillance of infections among patients and employees.

1. The ICP conducts surveillance of HAIs through

A. Review of culture reports and other pertinent lab data
B. Nurse consultation and referral
C. Medical record review
D. Personal consultation by employees
E. Follow-up communicable disease exposure.
F. Maintenance of the employee infection record
G. Physician consultation
H. Other

II. Specific definitions of healthcare-associated infections are used consistently (See "Definitions")

A. Healthcare-associated infections summaries
B. Line listing of infections
C. Other pertinent forms

Review of the Infection Prevention Manual revealed no documentation the manual was approved by:

Administrator
Medical Director
Director of Nursing
Board Approval

Facility Policy: Infection Prevention Committee

I. Purpose:

Prevention and control of healthcare-associated infections.

II. Infection Prevention Committee Responsibility:

Investigation, control, and prevention of infection
Review and approval of infection prevention policies and procedures
Receive reports from infection prevention team/unit committee
The infection prevention committee meets on a regular basis

IV. Reporting:

The infection preventionist prepares infection reports and presents them to the committee. Areas for improvement are identified and actions are planned for resolution.

V. Membership:

The infection control committee is composed of the following:

Infection Preventionist
Administrator
Director of Nursing
Medical Unit Department Manager
Bradford Unit Department Manager
Gateway Unit Department Manager
Emergency Department Manager
Laboratory Services Department Manager
Environmental Services Department Manager
Quality/Risk Manager


Review of the 2 Infection Prevention Committee meeting minutes revealed the following:

Meeting date: 5/23/13

Absent members were the Administrator, Director of Nursing, Emergency Department Manager, and the Laboratory Services Manager.

Topics included the following: Isolation Precautions: new signs needed, Infection Policies updated, and temperature logs. There was no documentation of the polices being approved as evidenced by no signatures on approval list, no reports from infection prevention team/unit committees and no documentation of infection reports from the ICP.

Meeting date: 2/11/14

Absent members were the Administrator, Gateway Unit Department Manager, Environmental Services Department Manger and the Laboratory Services Manager.

Topics included the following:

Temperature Logs: Monitoring for Compliance by performing weekly checks randomly.

Flu shots: Anyone who has not received the injection needs to obtain from the emergency room.


An interview was conducted with Employee Indentifer # 4, Director of Nursing on 5/29/14 at 1:00 PM. The surveyor asked EI # 4 what the policy meant by the Infection Prevention Committee meeting on a regular basis and the response was, "quarterly". The surveyor also requested documentation of the polices being approved, reports from infection prevention team/unit committees and documentation of infection reports from the ICP. None were provided.

No documentation was provided to the surveyor of second (April, May and June) quarter and third (July, August and September) quarter Infection Prevention Committee meeting minutes for 2013.

Based on review of medical records, personnel records, facility policies and procedures, Infection Prevention Committee meeting minutes, medication manufacturer's storage recommendations, washing machine disinfection/dryer filter check log, observations and interviews, it was determined facility failed to ensure:

1. Employees were screened annually with a tuberculin (TB) skin test per policy. This affected 10 of 19 employee files.

2. Washing machines and dryer lint filters were disinfected and cleaned according to the facility's policy.

3. Staff performed hand hygiene after blood glucose testing and following glove change.

4. Medication refrigerator temperatures were monitored daily and freezer defrosting was performed when needed.

5. Staff followed the policy for reporting animal bites to the proper authorities for patients presenting to the Emergency Department (ED) with animal bites.

This affected 2 of 2 patients seen in the ED with animal bites (Emergency Department Patient Indentifer) and did affect ED PI #s 14 and # 17. This had the potential to affect all patients presenting with animal bites.

The above deficient practices had the potential to negatively affect all patients served by the facility and all facility staff.


Findings include:

Policy: Tuberculosis Screening for Employees
Effective Date 5/13

Purpose:

To promote patient and employee safety and well-being by screening employees for tuberculosis and initiating appropriate follow-up...

Policy:

1. Tuberculin skin testing (TST)

A. New Employees

1. New employees who have been made a conditional offer of employment shall be screened for presence of infection with M. (Mycobacterium) tuberculosis using the Mantoux TST. Skin testing will employ the one-step procedure...

B. Additional employee screening

1. Employees with negative skin test history will have an additional one-step skin testing annually...

************

Policy/Procedure Title: Laundry Services
Review/Revised Date(s): 5/13

" Purpose: To assure a clean supply of linens and to protect employees who handle and process the laundry.

III. Gateway Behavioral Unit

1. Employees are allowed to use the washing machine and dryer for patient clothing.

2. After each use of the washing machine, an employee will disinfect the washing machine conducting a wash/rinse cycle using a Clorox solution..."

************

Policy/Procedure Title: Dryer Lint Cleaning
Review/Revised Date(s): 5/13

" Purpose: To assure a clean supply of linens and to reduce the risk of a fire.

Policy...

B. Gateway Behavioral Unit
1. Nursing staff are allowed to use the dryer for patient clothing.
2. After each use of the dryer, the lint filter in the dryer is cleaned by nursing staff..."

************

Policy/Procedure Title: Hand Hygiene
Review/Revised Date(s): 5/13

" Purpose: To reduce the risk of transmission of infection by appropriate hand hygiene.
To ensure compliance with the current CDC (Centers for Disease Control) hand hygiene guidelines.

Policy:

G. Decontaminate hands after contact with body fluids or excretions...
I. Decontaminate hands after contact with an inanimate objects (including medical equipment) in the vicinity if the patient.
J. Decontaminate hands after removing gloves...

III. Hand Hygiene Technique
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations..."

*************
Manufacturer's storage recommendations for Tuberculin Purified Protein Derivative (Mantoux):

www.fda.gov...
"...Tuberculin Purified Protein Derivative (Mantoux) - Food and ...
STORAGE
259 Store at 2? to 8?C (Celsius) (35? to 46?F{Fahrenheit}). (21) Do not freeze. Discard product if exposed to freezing. 260 Protect from light. Tuberculin PPD solutions can be adversely affected by exposure to light. 261 The product should be stored in the dark except when doses are actually being withdrawn from 262 the vial. (22) 263 A vial of TUBERSOL which has been entered and in use for 30 days should be discarded...."

*************
Manufacturer's storage recommendations for Risperdal Consta:

RISPERDAL? CONSTA? (risperidone) is available in dosage strengths of 12.5 mg, 25 mg, 37.5 mg, or 50 mg risperidone.

Storage And Handling

The entire dose pack should be stored in the refrigerator (36?- 46?F; 2?- 8?C) and protected from light.

*************

Policy/Procedure Title: Animal Bite
Effective Date: 4/13

Policy:
A rapid assessment will be performed on a patient presenting with an animal bite wound. The rapid assessment will provide an initial overview of the patient and will direct treatment...

7. Document the following on the ED (Emergency Department) record:
Notification of Police Department...
Notification of County Health Department...
Notification of Animal Control Office...

8. Have patient remain in the ED until the police arrive, even if the patient's own pet inflicted the bite, or if the animal belongs to someone the patient knows...


Review of 19 personnel records revealed 10 employees who were hired prior to May 2014 did not receive TB skin test annually according to the facility's policy.

An interview was conducted with Employee Identifier (EI) # 17, Human Resource on 5/29/14 at 2:00 PM. EI # 17 verified the above findings.

A tour of the Gateway psychiatric unit on 5/28/14 at 8:50 AM and the unit laundry room was inspected. There was no bleach or detergent found in the laundry room.

An interview with EI # 3, Registered Nurse (RN), Quality Manager (QM) at Gateway on 5/28/14 at 8:50 AM was conducted. EI # 3 reported staff "runs the washer disinfection cycle on the night shift and check the (dryer) filter after each shift."

An observation was made at 5/28/15 at 9:10 AM when bleach and detergent were delivered to the unit by the facility Housekeeping Manager, EI # 8.

Review of the Washing Machine Disinfection/Dryer Filter Check Log documentation revealed the following:

January 2014: 14 of 31 days washer disinfection and lint filter cleaning was documented. There were zero days documented where washer disinfection was performed more than one time a day.

February 2014: 15 of 29 days washer disinfection and lint filter cleaning was documented. There were zero days documented where the washer disinfection was performed more than one time a day.

March 2014: There was no documentation washing machine disinfection or dryer filter checks were performed for the month of March.

April 2014: 20 of 30 days washer disinfection and lint filter cleaning was documented. On 4/5/14, 4/10/14 and 4/25/15 the washer disinfection and lint filter cleaning was documented as performed two times these dates.

May 2014: 17 of 28 days washer disinfection and lint filter cleaning was documented. On 5/12/14 the washer disinfection and lint filter cleaning was documented as performed two times this date.

During an interview with EI # 3 on 5/28/14 at 9:35 AM, EI # 3 confirmed the psychiatric unit had been out of laundry supplies which had been replaced earlier in the morning. EI # 3 validated staff had not followed or documented washer disinfection and lint filter cleaning after each use as per facility policy.


An observation of care was performed 5/28/14 at 11:05 AM with EI # 7, Lab Manager. Capillary blood glucose testing was ordered for 3 unsampled patients.

EI # 7 entered the patient room with the blood glucose testing meter and supplies and donned gloves. EI # 7 attempted to obtain patient permission to perform the procedure but the patient refused. EI # 7 exited the patients room and the Geriatric Psychiatric unit of the department without changing gloves or performing hand hygiene. EI # 7 failed to decontaminate his hands after contact with an inanimate objects (the blood glucose testing equipment) in the vicinity if the patient.

EI # 7 then entered the Adult Psychiatric unit and patient number two's room and verified the correct patient. EI # 7 cleansed the patient's finger with an alcohol prep pad, performed the capillary blood glucose testing, verified the glucose results, removed/ discarded his gloves and exited the room. EI # 7 failed to perform hand hygiene after patient contact and contact with body fluids.

EI # 7 entered the third patient's room, donned gloves and performed the capillary blood glucose testing. EI # 7 removed the gloves, exited the patient room, entered the nurse station, and reported the test results.

EI # 7 failed to perform hand hygiene after contact with body fluids and glove removal.

EI # 7 failed to clean the glucometer between patient use.

An interview was performed on 5/28/14 at 11:10 AM with EI # 7. EI # 7 confirmed the above findings.

A tour of the Gateway nurse station was performed on 5/27/14 at 1:50 PM. The unit medication refrigerator was found to contain Lantus insulin, Tuberculin Purified Protein Derivative vaccine and injectable Risperdal.

Review of the Gateway Omnicell temperature log manual revealed the following:

April 4, 2014: no temperature monitoring documentation.
April 14, 2014: no temperature monitoring documentation.
April 25, 2014: no temperature monitoring documentation.

There was no documentation the Gateway Omnicell temperature log was monitored prior to April 1, 2014.

On 5/27/14 at 1:55 PM the surveyor performed an observation of the medication refrigerator. The refrigerator freezer section contained an excessive amount of ice build-up and needed defrosting.

An interview with EI # 3 was performed on 5/27/14 at 2:00 PM. EI # 3 asked EI # 9, Licensed Practical Nurse when the freezer was last defrosted. EI # 9 reported "sometime last week". There was no documentation to support the above.

Review of the 5/23/13 Infection Prevention Committee meeting minutes documentation revealed the topic of temperature logs was discussed and new temperature logs were to be emailed to department managers on 5/24/13 to begin use 6/1/13.

Review of the 2/11/14 Infection Prevention Committee meeting minutes revealed topic discussions for temperature logs that included monitoring for compliance with weekly checks and follow-up random audits.

An interview with EI # 3 on 5/28/14 at 10:10 AM, confirmed no further medication refrigerator temperature monitoring documentation was available for review and the facility had not followed it's policy.




34108

1. ED Identifier # 14 was admitted to the ED on 2/20/14 at 3:38 PM with the diagnosis of Dog Bite. The patient was treated and discharged to home. There was no documentation the police, health department, or animal control were notified of the bite wound.

2. ED Identifier # 17 was admitted to the ED on 2/7/14 at 7:30 PM, with the diagnosis of Dog Bite. The patient was treated and discharged to home. There was no documentation the police, health department, or animal control were notified of the bite wound.

An interview conducted on 5/29/14 at 9:15 AM with EI # 14, ED Manager, verified that the police, health department and animal control were not notified.