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Based on review of medical records, observation, staff interview and review of hospital policies, it was determined the hospital failed to ensure patients were provided a safe environment and protected from harm. The failure to implement appropriate safety precautions placed the safety of all patients admitted to the facility in immediate jeopardy. Findings include:

1. Refer to A 144 as it relates to the facility's failure to ensure patients' right to receive care in a safe setting was upheld and patients' health and safety were not placed in immediate jeopardy.

The cumulative effect of these negative systemic practices resulted in the inability of the hospital to keep patients safe from harm.

Based on medical record review, observation, staff interview and review of hospital policies, it was determined the hospital failed to ensure adequate precautions were taken protect patients with suicidal ideations from self harm. Appropriate safety precautions were not implemented for 4 of 9 patients (#3, #5, #7 and #8) whose records were reviewed. This resulted in one patient (#5) attempting suicide in October of 2012 by using hospital gowns with the strings tied together in an effort to attempt suicide by strangulation. These failures left this patient, and all subsequent potentially suicidal patients admitted to the facility, vulnerable and in immediate jeopardy of serious harm, impairment, or death. Findings include:

1. Patient #5's medical record documented a 69 year old male who was admitted to the facility on 10/20/12 at 4:00 PM. Diagnoses included bipolar disorder, PTSD by history, bulimia nervosa by history and borderline personality disorder.

The "INITIAL PSYCHIATRIC EVALUATION," dated 10/20/12 at 7:20 PM and completed by a physician, documented Patient #5 attempted suicide twice within 30 days prior to admission on 10/20/12. The document stated Patient #5 tried to strangle himself with dental floss during late September of 2012 when he was a patient in another local psychiatric hospital. The evaluation also documented Patient #5 attempted suicide by overdose on 10/19/12, while sitting in the parking lot of a local medical/psychiatric facility. He was admitted to ICU. When he was medically stable, he was placed on a mental hold in order to determine mental competancy. The document also included Patient #5 was admitted to the facility on 10/20/12 for "safety, further evaluation, and treatment on a hold... ...Disposition is unclear, it may be at [a state operated psychiatric facilily]."

The "ADULT ASSESSMENT," dated 10/20/12, untimed and signed by an RN, documented Patient #5's behaviors at the time of admission included "recent suicide attempts, depression and break up/separation with wife." The assessment described "breakup/separation w/wife" as a precipitating event. Additionally, documentation included Patient #5's refusal to discuss suicidal ideation/intent at the time of the assessment.

A document titled, "INITIAL SUICIDE ASSESSMENT," dated 10/20/12 at 4:00 PM, documented Patient #5 had "no apparent precipitating factor/event." The document also defined the 2 recent suicide attempts were "... Non-Lethal Attempt..." Written on the bottom of the form was "Patient is @ high risk potential with 2 current suicide attempts. Both attempts at care facilities." Once the document was completed, correlating points were assigned, tallied and "LEVEL II" suicide precautions were implemented for Patient #5. (Levels refered to the amount of supervision patients received for safety.)

On 10/20/12 at 10:00 PM, a nurse documented Patient #5 was found sitting on his bed with the strings of a hospital gown tied together. The note documented Patient #5 was "Holding very tight between hand in attempt to strangle himself." The progress note documented Patient #5 said "I just want to leave this world."

A physician order, dated 10/20/12 at 9:00 PM, stated "Level I Suicide precautions 1/1 [staff supervision] d/t pt tying gown strings together in attempt to strangle himself."

The DON was interviewed about safety precautions and the "INITIAL SUICIDE ASSESSMENT" form on 12/21/12, beginning at 9:23 AM. She reviewed the form and stated patients on "LEVEL II" suicide precautions were monitored/checked every 15 minutes. When asked the criteria for implementing 1:1 supervision, the DON said a patient should be actively suicidal, have a plan to commit suicide and have a history of prior suicide attempts.

Appropriate safety precautions, based on Patient #5's initial assessment, were not implemented at the time of admission.

2. Patient #3's medical record documented a 37 year old male who was admitted to the facility on 12/06/12 at 8:30 PM. Diagnoses included mood disorder, rule out bipolar disorder, and major depressive disorder.

The "INITIAL PSYCHIATRIC EVALUATION," dated 12/06/12 at 2:58 PM and completed by a physician, documented Patient #3 was admitted following an overdose on 12/05/12. According to documentation, he became unresponsive, was transported to a local ER and intubated to protect his airway. The documentation also indicated the trigger, or precipitating event, was a fight with his wife and adolescent daughter who ran away. Documentation also said Patient #3 initially denied he was suicidal, but then acknowledged he had been hospitalized approximately 7 times for suicidal thoughts. The evaluation also stated "He seems to have no insight into the seriousness of his attempt and he is at great risk for further harm to himself. ...He will be on q. 15 minute checks and suicidal precautions."

The "ADULT ASSESSMENT," dated 12/07/12, untimed and signed by an RN, documented Patient #3's behaviors at the time of admission included a history of suicide attempt by overdose on prescription drugs. The assessment described a fight with his wife as the precipitating event for Patient #3's suicide attempt and resulting hospitalization.

A document titled, "INITIAL SUICIDE ASSESSMENT," dated 10/07/12 at 3:00 PM, documented Patient #3 had a "Minor Catastrophic Life Change" as the precipitating event. The document also defined the intensity of suicidal ideation as "Acute, recent onset with or without precipitant" and the lethality of the attempt as "Obvious Lethal Attempt with past 90 days." The 2 recent suicide attempts were "... Non-Lethal Attempt..." Once the document was completed, correlating points were assigned, tallied and "LEVEL II" suicide precautions were implemented for Patient #3. "Place level II with q 15 min checks" was written on the bottom of the document.

On 12/19/12 at noon, a physician documented Patient #3 was informed that he would soon be transferred to a state operated psychiatric facility. Documentation also included "There is some concern given his impulsivity in the past that about hearing this news, there will be the possibility of self harm, however, staff is all aware of his history and the fact that he just heard this news and we are going to keep a very close eye on him and if there is any concern at all about his safety, we will put him on 1:1."

The DON was interviewed on 12/21/12, beginning at 2:23 PM. She reviewed Patient #3's medical record and was unable to locate documentation that indicated the level of observation changed/was increased after the physician's progress note on 12/19/12. She was unable to explain what "keep a very close eye on him" meant for the nursing staff. The DON confirmed Patient #3 remained on 15 minute checks, but stated it would have been appropriate to maintain line of sight for Patient #3.

Appropriate and clearly defined safety precautions were not documented for Patient #3.




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3. Patient #8's record documented a 30 year old male admitted to the facility on 12/23/2012 on an involuntary mental hold for a recent suicide attempt. The "INITIAL PSYCHIATRIC EVALUATION," dated 12/23/12, stated Patient #8 had a history of seizures, depression, bipolar disorder, schizophrenia and past suicide attempts in January and November of 2012 (attempted overdose.) According to the evaluation, the patient and his wife had an argument and she tried to close a door on him. The evaluation stated prior to admission the patient banged his head against the door finally breaking through the door, resulting in a laceration to his forehead. According to the evaluation, the patient then began to burn some pictures but his wife thought he was trying to burn the house down and the police were called. The evaluation stated that when the police arrived, Patient #8 had grabbed a butcher knife and held it to his stomach. The evaluation stated the patient was taken into custody and brought to the hospital.

A document titled "INITIAL SUICIDE ASSESSMENT" was completed on 12/23/12 at 11:00 PM and signed by an RN. The instructions on the form indicated the RN was to "check the most applicable criterion and add the score. Divide by 4 to determine the assessed level. Circle the assessed level, date, time, and sign the assessment." According to the document, under the category "NATURE OF PRECIPITATING EVENT" the RN scored a 1 for "Minor Catastrophic Life Change." It was unclear what a "Minor Catastrophic Life Change" meant. Documentation indicated under the category "TIME SINCE PRECIPITATING EVENT" the RN scored a 3 for "One week or less." According to the document, under the category "INTENSITY OF SUICIDAL IDEATION" the RN scored a 3 for "Acute, recent onset with or without precipitant." According to the document, under "LETHALITY OF ATTEMPT" the RN scored a 1 for "Obvious Non-Lethal Attempt." Patient #8 was threatening himself with a knife. It was not clear what "Obvious Non-lethal Attempt" meant. The document indicated the "LEVEL II" was circled. The form was open to the interpretation of the RN.

The "ADMISSION ORDERS" included "level II suicide precautions" handwritten on the document.

In an interview on 12/21/12 beginning at 9:20 AM the DON explained the "INITIAL SUICIDE ASSESSMENT" forms were completed by the RN from the RN's perception of the patient's situation. The DON explained that a level I lead to one to one supervision, meaning the patient is within arms reach of staff. The DON stated one to one supervision is for a patient that is actively suicidal, has a plan, and has made suicide attempts. The DON stated a level II means the staff will check on the patient every 15 minutes. The DON stated a level II patient is a patient that is not currently suicidal and does not have a plan and a level III is for patients that are close to discharge. The DON stated supervision provided for level II and level III patients was the same. The DON stated that 15 minute checks were done for all patients except those requiring one to one supervision, regardless of the level the patient scores. The DON stated there were no assessments to evaluate for assault and elopement risk. The DON was asked how the level system keeps the patients in the facility safe and the DON replied "I know they are safe because the 15 minute checks are being done."

According the "ADULT ASSESSMENT," dated 12/24/12, Patient #8 stated the reason he had been admitted was because he "was going to stab himself in the heart." The document titled "MASTER TREATMENT PLAN REVIEW" contained documentation from 12/27/12 that Patient #8 "remains depressed with active suicidal ideation w/specific scenarios." This document also stated Patient #8's "current symptoms of depression with SI (suicidal ideation) limited his ability to be safe at this time" and that Patient #8 is "on level II suicide precautions."

Nursing notes dated 12/27/12 at 9:45 AM indicated the patient "reports positive suicidal ideation (with) plan to stab himself. Level II suicide precautions per (physician). Q 15 min (checks)." Nursing notes dated 12/27/12 at 10:00 PM stated "Pt did report suicidal ideation (with) plan to stab self paces on unit (continue) (with) q 15 (and) plan of care." Nursing notes dated 12/26/12 at 10:15 AM documented "pt (up) to counter reports he does have suicidal ideation but unsure of plan to harm self but gave several scenarios of other people attempts. Staff to monitor for (changes)." There was no documentation in the record to indicate the patient was on any other suicide precautions beside every 15 minutes checks.

The document titled "PROGRESS NOTES FORM - SOCIAL SERVICES" dated 12/27/12 at 9:00 AM, stated "pt continues to have SI with multiple plans such as stabbing himself in the heart, overdosing on medications, or using a nailgun."

Patient #8's medical record did not document the reason he was assigned a level II suicide precaution and did not document that his level of supervision was reassessed.

The hospital did not clearly evaluate Patient # 8's suicide risk.

4. Patient # 7's "INITIAL PSYCHIATRIC EVALUATION" recorded a 27 year old male admitted to the facility on 12/10/12 for depression with suicidal ideation. The evaluation stated the patent had a history of depression, schizo-affective disorder, post-traumatic stress disorder and substance abuse. According to the evaluation, Patient #7 was on probation and unable to leave the state, working a "dead-end job," had financial problems and problems with his family. The evaluation stated he was married but separated from his wife and lived in a halfway house. The evaluation stated Patient #7 had recently spoken with his wife which "was very upsetting to him." The evaluation stated he told his roommate he was going to kill himself. The evaluation stated "thought content was positive for suicidal thoughts with suicidal intention of killing himself once he was alone at night by cutting himself." According to the evaluation, Patient #7 had admitted to cutting himself in the past but had never attempted suicide before.

The document titled "INITIAL SUICIDE ASSESSMENT" was completed and signed by an RN on 12/10/12 at 3:30 PM. The instructions on the form indicated the RN was to "check the most applicable criterion and add the score. Divide by 4 to determine the assessed level. Circle the assessed level, date, time, and sign the assessment." According to the document, under the category "NATURE OF PRECIPITATING EVENT" the RN scored a 0 for "No apparent precipitating factor." The document did not clearly define what precipitating factors were. According to the document, under the category "TIME SINCE PRECIPITATING EVENT" the RN scored a 3 for "One week or less." According to the document, under the category "INTENSITY OF SUICIDAL IDEATION" the RN scored a 3 for "Acute, recent onset with or without precipitant." According to the document, under "LETHALITY OF ATTEMPT" the RN scored a 1 for "Obvious Non-Lethal Attempt." The document did not clearly specify what qualified as lethal. The document stated the "LEVEL II" was circled however, according to the scoring instructions on the document, the patient actually scored 1.75 which would have made the patient a "LEVEL III." The document was open to the interpretation of the RN.

There was no documentation of an order signed by a physician for level II precautions.

In an interview on 12/21/12 beginning at 9:20 AM the DON explained the patient would be placed on "LEVEL II" suicide precautions automatically if there was no immediate order from the physician stating a specific level of observation.

A document titled "PROGRESS NOTES 2/12/12" dictated 12/12/12 at 6:14 PM and signed by the physician 12/14/12, stated that Patient #7's thought content was positive for suicidal thoughts. The note also stated "the patient is still at elevated [increased] risk of self harm." "PROGRESS NOTES 2/14/12" dictated 12/14/12 and signed by a physician on 12/18/12 recorded Patient #7's "thought content is positive for thoughts of cutting and suicidal thoughts." The progress notes also stated "the patient remains at elevated risk of self harm at this time." "PROGRESS NOTES 12/18/12" dictated 12/18/12 and signed by a physician 12/19/12, indicated Patient #7 "wishes he was not alive, he hates his life, and he feels 'so mad at this world." The note stated "he is having thoughts of overdosing on medications to end his life after he leaves the hospital." The note stated the patient "continues to be at elevated risk of self harm." It was not clear what was meant by "elevated risk of self harm." There was no documentation to indicate Patient #7's suicide observation level was reassessed.

The DON was interviewed on 12/21/12 beginning at 9:20 AM. She reviewed the medical record and did not have an explanation about why the description of the patient's risk for self harm did not instigate a higher level of observation.

A note written on 12/14/12 at 2:15 PM on the form titled "Interdisciplinary Progress Notes" contained documentation from a Certified Psychiatric Technician that Patient #7 "stated he was feeling like he wanted to hurt himself. He said...if he had a knife he would cut himself. Pt stated not sure what started his feeling like this but was having thought of being worthless." The note stated "staff reassured pt he was safe. Pt said he felt better after talking and went back to group after encouragement from staff to not be alone." A nursing note dated 12/14/12 at 3:00 PM stated "pt denies S/I, H/I or A/V hallucinations at this time but did report to pharm(asist) that he was hearing voices and seeing things (ie pencil) move by itself. No acute distress noted, will con't to monitor level II (with) q 15 min checks." There was no documentation that this encounter with Patient #7 was reported to an RN or physician or that Patient #7 was reassessed for a change in suicide precaution level.

Patient #7's medical record did not document the reason he was assigned a level II suicide precaution and did not document that his level of supervision was reassessed.

The hospital did not clearly evaluate Patient # 7's suicide risk.



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5. The policy manual on the nursing unit contained a policy titled "LEVELS OF OBSERVATION," dated 11/04/04. The policy stated patients would be assessed on admission for the appropriate level of precaution by a physician. The policy did not state the nurse's role in the assessment of patients in order to determine the level of observation required to keep patients safe from harm. The remainder of the policy listed the procedure for one to one observation and 15 minute observations.

The "LEVELS OF OBSERVATION" policy further stated staff was to document the monitoring of patients on "Form NS 4a.3.3.1." The Director of Health Information was interviewed on 1/04/13 beginning at 11:50 AM. She stated there was no "Form NS 4a.3.3.1" and she did not know what document the policy referred to.

A document titled "Suicide Precautions," not dated, was contained in a "Nursing Resource Manual" at the nursing station. It contained conflicting information from the above policy. It stated the RN assessed patients and notified the psychiatrist "...of a disturbed patient who may need initiation of suicide precautions..." It stated a physician's order for suicide precautions would be documented in the medical record when the procedure was implemented. The document described 3 levels of suicide precautions. Level I required one to one continuous nursing observation 24 hours a day. Level II was assigned to patients who "...present clinical symptoms that indicate a higher suicide potential than Level III. Nursing care for Level II patients was listed as "Continuous nursing observation in line of sight in a designated area and interaction 24 hours a day..." Level III was assigned to "Those patients who have suicidal ideations and, after assessment by the RN and/or psychiatrist, are assessed to be in minimal danger of actively attempting suicide." Level III required 15 minute checks and doors to remain open. The document stated "A no-harm contract will be signed daily and when the level of precaution changes."

A document titled "OBSERVATION POLICY," not dated, was an extensive 7 page policy. The policy listed 3 levels of observation and outlined staff's duties for each level. The policy did not specifcally address precautions such as suicide, assault, or elopement precautions.

The Charge Nurse was interviewed on 12/21/12 beginning at 11:00 AM. When asked to find the policy for observation of patients and levels of supervision, he produced the policy titled "LEVELS OF OBSERVATION," noted above. Later that morning, he stated he found the document titled "Suicide Precautions" in a "Nursing Resource Manual" at the nursing station. He stated these were the only 2 documents related to supervision levels he was aware of. He stated he was not aware of a policy addressing other precautions such as assault precautions and elopement precautions.

The DON was interviewed on 12/21/12 beginning at 1:45 PM. She stated the hospital was using the policy "OBSERVATION POLICY." She described this policy as "current but not final." She confirmed the hospital policies did not address precautions other than suicide precautions.

Hospital policies did not provide clear, consistent, comprehensive guidance related to levels of supervision required to maintain safety.

NOTE: On Thursday 12/27/12 at approximately 2:45 PM, the CEO was notified of the immediate jeopardy related to the facility's failure to ensure valid, comprehensive patient assessments were completed and appropriate precautions implemented to protect the patients from immediate jeopardy. As a result of this failed practice, the safety of all subsequent patients admitted to the facility was found to be at risk.

A plan for immediate correction was received, reviewed, and accepted on 12/28/12 at approximately 2:30 PM. The plan included the development of a new "Safety Precautions and Categories of Observation" policy and procedure. The new policy documented that all patients admitted to the inpatient unit would be monitored in compliance with physician orders and prescribed protocols. The procedure provided the option of 3 categories of observation from which the physician could choose based on assessment and current condition of patients. The categories included 15 minute checks/observation, maintaining line of site and 1:1 observation. Also included was instruction to assess and obtain orders for precautions related to suicide, elopement, assault, behavioral, sexual perpetration, sexual victimization, self-harm, falls and seizures.

A "High Risk Notification Alert" form was also implemented, which the policy indicated should be completed by the nurse at the time of admission and when a change related to safety precautions occurs. The form stated, "If any risk factors are checked, individualized precautions must be ordered to ensure patient safety." Possible risk factors listed on the form were "Homicidal, Suicidal, Sexual Perpetration - Acting Out, Risk of Being Sexually Victimized, Self Harm, Fall Risk, Medically Compromised, Elopement Risk and Detox."

Education of the clinical staff about the new policy/procedure related to safety precautions and categories of observation was initiated on 12/28/12. Education on the use of the "High Risk Notification Alert" form was included as well. The plan was to continue educating clinical staff before their next scheduled shift to work until all staff were educated. The DON and/or trained RN designee were responsible for providing training.

Implementation of the above plan was verified through observation of training. The CEO was notified on 12/28/12 at approximately 4:00 PM, that the immediate jeopardy was abated.

6. Surveyors toured the facility on 12/19/12, beginning at 2:15 PM. Tour of patient rooms revealed electric hospital beds with exposed electrical cords. The cords were visible and long enough to extend from the electrical outlet and lay on the floor.

The Building/Grounds Maintenance Manager and CEO was interviewed on 12/21/12, beginning at 1:45 PM. The Building Maintenance Manager confirmed that all patient beds in the facility except 2 were electric with attached, exposed cords. He and the CEO confirmed the exposed cords presented a potential risk to current and future patients who were admitted with suicidal ideation/intent.

The hospital did not maintain a safe environment for patients at risk of self injurious behavior.

Based on staff interview and review of medical records, policies, meeting minutes, and QAPI documents, it was determined the hospital failed to ensure a data driven QAPI program had been developed, implemented, and monitored. This resulted in the inability of the hospital to evaluate its processes and practices. Findings include:

1. Refer to A266 as it relates to the failure of the hospital to ensure adverse patient events were analyzed and tracked.

2. Refer to A273 as it relates to the failure of the hospital to ensure a QAPI program had been developed and implemented that assessed processes of care and used data to monitor the effectiveness of services.

3. Refer to A283 as it relates to the failure of the hospital to ensure the QAPI program used data to evaluate and change systems to improve patient care.

4. Refer to A297 as it relates to the failure of the hospital to ensure the QAPI program included performance improvement projects.

5. Refer to A309 as it relates to the failure of the hospital to ensure the governing body assumed responsibility for implementing and monitoring the QAPI program.

The cumulative effect of these negative facility practices prevented the hospital from utilizing data to improve its processes.

Based on staff interview and review of incident reports and QAPI documents, it was determined the hospital failed to ensure adverse patient events were analyzed and tracked. This affected the care of 1 of 2 patients (#5) who attempted suicide in the facility. This resulted in the inability of the hospital to evaluate systems in order to determine how patients could be protected from harm. Findings include:

1. The hospital completed incident reports for some adverse patient events. Incident reports were reviewed for 2012. These consisted of falls, medication errors, minor injuries to patients, and 1 elopement. The numbers of these events were then listed by month on the facility "Report Card." The Report Card just listed numbers but no documentation was present that an analysis of the data had occurred.

The DON was interviewed on 12/28/12, beginning at 11:15 AM. She stated no trending of the number of incidents was conducted. She stated the data had not been used to analyze trends of certain events, such as falls, in order to change practices to decrease the number of events.

2. Not all adverse patient events were documented in incident reports so the data could be captured and analyzed.

Patient #5's medical record documented a 69 year old male who was admitted to the facility on 10/20/12 at 4:00 PM. Diagnoses included bipolar disorder, PTSD by history, bulimia nervosa by history and borderline personality disorder.

The "INITIAL PSYCHIATRIC EVALUATION," dated 10/20/12 at 7:20 PM, documented Patient #5 attempted suicide twice within 30 days prior to admission on 10/20/12. The document stated Patient #5 tried to strangle himself with dental floss during late September of 2012 when he was a patient in another psychiatric hospital. The evaluation also documented Patient #5 attempted suicide by overdose on 10/19/12. He was admitted to the ICU at a local hospital and transferred to Boise Behavioral Health Hospital when he was medically stable.

On 10/20/12 at 10:00 PM, a nurse documented Patient #5 was found sitting on his bed with the strings of a hospital gown tied together. The note documented Patient #5 was "Holding very tight between hand in attempt to strangle himself." The progress note documented Patient #5 said "I just want to leave this world."

The DON was interviewed on 12/28/12, beginning at 11:15 AM. She stated an incident report had not been completed when Patient #5 attempted to strangle himself. She also stated an investigation of the incident had not been documented. This did not allow the hospital to assess its systems to keep patients safe and determine how future events could be prevented. It also brought into question the accuracy of the number of incidents that had been reported.

The hospital did not track and analyze at least one significant adverse patient event.

Based on staff interview and review of policies, meeting minutes, and QAPI documents, it was determined the hospital failed to ensure a QAPI program had been developed and implemented that assessed processes of care and used data to monitor the effectiveness of services. This resulted in the inability of the hospital to change its processes in response to patient outcomes. Findings include:

The policy "Performance Improvement Policy and Procedure," not dated, stated each department would identify problems and bring them to the committee. The committee then was to identify the top 2 or 3 problems and assign subcommittees to address them. The subcommittees were to write and implement action plans to correct identified problems. No evidence was present that committees met on a regular basis and developed and implemented a comprehensive QAPI program. Examples include:

1. PI committee minutes for 2012 were requested from the DON. She provided "PERFORMANCE IMPROVEMENT MEETING MINUTES," dated 2/16/12. These were reviewed with her beginning at 9:15 AM on 12/28/12. She stated these were the only "PERFORMANCE IMPROVEMENT MEETING MINUTES" documented for 2012. The 11 page minutes discussed physical therapy audits, mainenance checks, and nursing record audit that had been completed prior to the meeting. The minutes did not discuss an assessment of problem areas nor did it set priorities to improve patient outcomes. The minutes did not include an overall plan for the QAPI program for 2012. The DON stated no other minutes of the PI Committee were documented for 2012. She stated a QAPI plan for 2012 was not documented. She stated she was not aware of the existence of a comprehensive QAPI plan, including the hospital's quality priorities. During the same interview, the DON stated the Coordinator of the QAPI program had left in January or February of 2012 and had not been replaced. She stated currently there was no person in charge of the hospital's QAPI program.

2. The hospital continued to produce a "Report Card" which included data that had been gathered monthly from January through November 2012. The "Report Card" contained data for areas of patient satisfaction, employee monitors, risk management, medical record reviews, active treatment measures, outcomes, and financials. However, there was no evidence of changes made to hospital practices based on the the data. For example, the monthly "Fall Rate" between January 2012 through October 2012 ranged between 0 and 19.1. No documentation was present to explain what these rates meant or what, if any, steps were taken to reduce the number of falls. Also, the monthly delinquency rate for the completion of discharge summaries between January 2012 through November 2012 ranged between 0 and 6%. A goal for discharge summary delinquency rates was not specified and documentation of steps taken to decrease the number of late discharge summaries was not present.

The lack of data analysis was confirmed by interview with the DON on 12/28/12 beginning at 9:15 AM.

3. Except for patient satisfaction indicators, the only listed quality indicators related to patient care on the "Report Card" were numbers of falls, assaults, medication errors and drug reactions, transfers, deaths, infections, restraints, and delinquent discharge summaries, the percentage of groups run as scheduled, and the percentage of patients who attended groups. A deeper examination of the systems that led to the numbers, such as such as nursing or pharmacy processes, was not included in QAPI documents.

The lack of quality indicators and analysis of the data collected was confirmed by interview with the DON on 12/28/12 beginning at 9:15 AM.

4. The DON was interviewed on 12/28/12 beginning at 9:15 AM. She was asked if any hospital processes had changed in the past year based on data gathered from the QAPI program. She stated she was not aware of any changes made as a result of the QAPI program.

The hospital did not define its QAPI program, develop a current QAPI plan, or analyze data to assess its processes.

Based on staff interview and review of meeting minutes, it was determined the hospital failed to ensure the QAPI program used data to evaluate and change systems to improve patient care. This resulted in the inability of the hospital to methodically analyze its processes. Findings include:

Only one set of minutes from the hospital's PI committee were documented for 2012. These "PERFORMANCE IMPROVEMENT MEETING MINUTES" were dated 2/16/12. The minutes included a report of QAPI activities at the hospital to date. The minutes did not identify high-risk, high-volume, and problem-prone areas nor did they suggest priorities for upcoming studies. Some data was included in the report such as numbers of incidents and percentages of physical therapy evaluations completed within 24 hours but an analysis of the data was not documented. The minutes did not identify opportunities for improvement or changes to processes. No other PI committee meetings were documented.

The DON was interviewed on 12/28/12 beginning at 9:15 AM. She stated a current QAPI plan that set priorities for its performance improvement activities and focused on high-risk, high-volume, and problem-prone areas had not been developed. She stated she was not aware of documents that included an analysis of QAPI data or set quality priorities for 2012.

The hospital did not use data to improve its processes.

Based on staff interview and review of policies and QAPI documents, it was determined the hospital failed to ensure the QAPI program included performance improvement projects. This resulted in the inability of the hospital to conduct in depth examination of its processes in order to determine the effectiveness of patient care. Findings include:

No performance improvement projects were documented for 2012 in the "PERFORMANCE IMPROVEMENT MEETING MINUTES," the Report Card, or Governing Board meeting minutes.

The policy "Performance Improvement Policy and Procedure," not dated, described the hospital's QAPI program. The policy did not mention performance improvement projects.

The DON was interviewed on 12/28/12 beginning at 9:15 AM. She confirmed the policy and stated the hospital had not conducted performance improvement projects in 2012.

The hospital failed to conduct performance improvement projects.

Based on staff interview and review of meeting minutes, it was determined the hospital failed to ensure the governing body assumed responsibility for implementing and monitoring the QAPI program. This resulted in the lack of a comprehensive QAPI program to analyze the hospital's systems and implement changes to improve patient care. Findings include:

Five "Governing Board Committee Minutes" were documented from 12/01/11 through 12/26/12. These occurred on 12/13/11, 3/02/12, 6/21/12, and 9/11/12. In addition, a special ad hoc meeting was documented on 8/07/12 to discuss physician credentialing.

The 12/13/11 "Governing Board Committee Minutes" documented a report on QAPI activities throughout the hospital. The minutes did not discuss QAPI planning for 2012.

The 3/02/12 minutes documented under "Risk Management/PI" the following: "One out-patient grievance: HIPPA violation was investigated. 1. Chemical/physical restraint: document face to face. 2. Strengths/attributes and intellectual functioning on all psychiatric evaluations. 3. Assure patient is appropriate for admission.: 1 to 17 MMSE."

The 6/21/12 minutes documented under "PI/Risk Management" the following: "[The administrator] summarized the last quarter for both meetings."

The 8/07/12 minutes did not address quality.

The 9/11/12 minutes documented under "PI/Risk Management" the following: "[staff name] quarterly compliance. He suggested that we focus on safety issues, facility wide."

The corporate Regional Vice President for the Behavioral Health Region was interviewed on 12/28/12 beginning at 2:50 PM. She stated she attended most of the Governing Board meetings. She confirmed the meeting minutes and the lack of documentation of direction and monitoring by the Governing Board. She stated the Board talked about quality a lot but it was not documented. She stated the administrator was new to the position. She stated the previous administrator had more documentation on quality and she would look for it on 12/30/12. The DON was contacted on 1/02/13 at 9:00 AM. She stated staff had looked for more documentation related to the Governing Board and quality but none had been found.

The Governing Board did not assume responsibility for direction and oversight of the QAPI program.