HospitalInspections.org

Based on staff interview and document review conducted on 9/4/19, it was determined that the facility failed to ensure that personnel are licensed as required by State or local laws.

Findings include:

1. Upon interview on 9/4/19 at 2:00 PM, in the conference room, Staff #22 stated that she/he was a registered nurse, on duty to West Unit.

2. Review of Staff #22's personnel file contained a Board of Nursing license that was valid to 5/31/2017.

3. Upon request, the facility failed to provide evidence with a valid Board of Nursing license for Staff #22, at the time of the survey.

4. The above findings were confirmed with Staff #1, Staff #2, and Staff #4.

Based on observation, staff interviews, and review of facility documents conducted September 3, 4 and 5, 2019, it was determined that the Governing Body failed to demonstrate it is effective in carrying out responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

Findings include:

482.12 Governing Body (Cross refer to tag A 046)

482.13 Patient Rights (Cross refer to tag A 144)

482.21 Quality Assurance (Cross refer to tag A 286, Cross refer to Tag A 701)

482.28 Dietary Services (Cross refer to tag A 620)

482.30 Utilization Review (Cross refer to tag A 654)

482.40 Physical Environment (Cross refer to tag A 701)

482.42 Infection Control (Cross refer to tag A 749)

Based on staff interviews and document review, it was determined that the governing body failed to ensure that the members of the medical staff were appointed.

Findings include:

1. During the entrance conference on 9/3/19 at 10:15 AM, Staff #7 stated that he/she was appointed as the medical director for the facility in the year 2018.

2. Upon request, Staff #1, Staff #2, and Staff #7 were unable to provide evidence that Staff #7 was appointed as a medical director.

3. The above finding was confirmed by Staff #1, Staff #2, and Staff #3.

Based on observation, staff interviews and review of facility documents, it was determined that the facility failed to ensure environmental risks are conducted to safeguard patients from harm.

Findings include:

1. The facility failed to ensure that all patients have the right to receive care in a safe setting. (Cross refer to Tag A 144)

A. Based on observation, staff interview, and medical record review, it was determined that the facility failed to ensure potential ligature points are identified to provide patients a safe setting.

Findings include:

1. On 9/4/19 at 11:00 AM in the presence of Staff #27, the following safety concerns were identified during a tour of the facility:

a. Light fixtures on the wall above the head of twenty (20) of twenty (20) patient beds located on the East Wing were equipped with one half inch metal bands that extended from the top of the light fixture and extended around the front of the fixture to the underside. These bands provided an approximate of half to one inch space that would provide a ligature point. Each of the twenty (20) light fixtures were equipped with (3) of these metal bands.

(i) During interview, Staff #27 stated, "the bands were installed to prevent the patients from accessing the lenses, light bulb, and live electrical socket".

(ii) Staff #27 confirmed, the metal bands around the light fixtures were unmitigated ligature risks.

b. Staff #27 also confirmed that no environmental risk assessment has ever been conducted to determine what environmental risks exist.

2. A large clear plastic bag was located in the trash cans in the front dayroom, and in the hallway in front of the medication room.

a. Plastic bags are a potential risk for patients who are at risk for suicide.

b. The facility failed to provide a safe setting for patients at risk for suicide.


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3. Review of Medical Record #5 revealed the following:

a. Physician / Licensed Independent Practitioner (LIP) Restraint & Seclusion Progress Notes dated 4/4/19 at 12:45 PM states, "...Patient was in dining room, grabbed another patient's plate, charged at another patient, staff intervened..."

b. Nursing Progress Notes dated 9/4/19 states, " At (12:40 p) hit pt RA [initials of patient] on head with dinner plate (top of) [sic]..."

c. During interview Staff #2 and Staff #10 confirmed that the facility provides meals on Yanco China plates, which are breakable upon force.

4. During an interview on 9/4/19, Staff #27 stated the following:

a. The hospital does not conduct environmental risk assessments of the patient care areas.

b. The hospital does not have any policies and procedures to address environmental risk assessments.

c. The hospital does not educate patient care staff in the identification of potential ligature points.


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B. Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that all patients are protected from potential criminal acts.

Findings include:

1. Review of Medical Record #5 indicated the following:

a. The Nursing Progress Notes, dated 9/1/19, states, a Police Officer had responded to a 911 call that Patient #5 made that morning, alleging that he/she was raped by his/her roommate three days prior, on 8/29/19 at 8:00 PM.

(i) The facility became aware of the above information when a Police Officer responded to the call by presenting to the unit on 9/1/19 at 9:20 AM.

(ii) Patient #5 was aggressive towards staff, threw his/her lunch tray on the nurse's desk, and was placed on, " ... 1-1 (LOS) [Line of Sight] ..." for safety.

2. Review of Medical Record #11 on 9/4/19 indicated the following:

a. The Nursing Progress Notes, dated 9/1/19, states that Patient #11 was accused of raping his/her roommate three days prior, on 8/29/19 at 8:00 PM.

b. The Nursing Progress Notes, dated 9/4/19, states, "... Reported by patient [Patient #11] and staff that the patient [Patient #11] got hit by a male patient ... during lunch time. As per staff that incident was unprovoked. Patient [Patient #11] assessed by staff ... Patient occipital area sore to touch ..."


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C. Based on observation and record review, it was determined that the facility failed to ensure that all patients are within the line of sight for a 1:1 Observation.

Findings include:

Reference: Facility policy titled, "Unpredictable Behavior Precautions - 1 to 1 Observation states, "...a. Line of sight observation requires that the patient is kept within eyesight and accessible at all times, by day and by night. This includes when the patient is outside his/her room in the shower or using the bathroom facilities...."

1. During a tour of the West Unit on 9/3/19, the following was revealed:

a. At 11:34 AM, Patient #6 went into the bathroom, then closed the door.

i. Staff #19 sat outside the bathroom door.

ii. A physician's order dated 9/3/19 at 09:20 AM states, "Cont. [continue] 1:1 observation (line of sight) for unpredictable beh. [behavior]."

iii.. Patient #6 was not within the line of sight during that time.

iv. The facility failed to ensure Patient #6 was monitored in accordance with the facility policy and procedure.

D. Based on observation, staff interview and patient interview, it was determined that the facility failed to ensure all patients are safe from falls.

Findings include:

1. During a tour of the West Unit on 9/3/19, the following was observed:

a. Patient #10 was observed wearing a pair of loosely fitted sneakers, in which the shoelaces were removed.

b. The tongue of each sneaker was flipped backwards and extended across the front.

c. The sneakers flapped on and off as Patient #10 ambulated.

d. Upon interview, Patient #10 stated that he/she was not provided with a means to secure his/her sneakers.

e. The facility failed to ensure patient safety is maintained.

2. This finding was confirmed with Staff #5.


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E. Based on observation and staff interviews, it was determined that the facility failed to ensure the patient has a way to communicate with staff.

Findings include:

1. On 9/3/19 at 2:25 PM, while on tour of the East Unit, the following was observed:

a. The East Unit has a total of eleven (11) patient rooms. Nine (9) rooms are double occupancy and two (2) rooms are private. It was not evident that the patients on this unit had a means to communicate with staff at all times, from their assigned rooms and/or in an emergency situation.

b. Staff #30 stated if a patient requires the assistance from a nursing staff member, the patient would ambulate to the nursing station to make his/her needs known. Furthermore, patients identified as high fall risk would be assigned to a room as close to the nursing station as possible. The [IA] Institutional Aides round on the patients every 15 minutes to assess safety and determine needs.

2. The above was confirmed with Staff #23.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure patient safety during an investigation of a potential criminal act in accordance with facility policy.

Findings include:

Reference: Facility policy titled, Sexual Activity, states, "... Procedure: ... C. Assault procedure for the assailant ... 2. Consideration shall be given to transferring the patient to another unit. 3. Consideration shall be given to transferring the patient to another facility ..."

1. There was no documented evidence that consideration was given to transferring Patient #11 to another unit or facility on 9/1/19 at 9:20 AM when the facility became aware of a potential sexual assault, as required by facility policy, until three days later, on 9/4/19, after a physical attack occurred.

a. The Facility became aware of rape allegations made by Patient #5 against his/her roommate, Patient #11, when a police officer responded in person to a 911 call on 9/1/19 at 9:20 AM.

(i) During an interview on 9/5/19, Administrative Staff #2 stated that the facility was made aware of Patient #5's allegations when a police officer arrived at the facility on the morning of 9/1/19.

(ii) A review of Medical Record #5 indicated that both patients remained roommates until the dayshift of 9/2/19.

(iii) During an interview on 9/4/19 at 1:02 PM, Staff #34 confirmed that Patient #5 and Patient #11 remained roommates until the day shift of 9/2/19 and then remained on the same unit afterwards.

b. A review of Medical Record #11 revealed that Patient #11 was hit on the head by Patient #5 in an unprovoked attack on 9/4/19 during "lunchtime". After this incident, a physician order was placed at 3:00 PM to transfer Patient #5 to another unit, " ... for Safety measures ..."

(i) During an interview on 9/4/19 at 1:02 PM, Staff #34 stated that Patient #11 was hit by Patient #5 in an unprovoked attack on 9/4/19.

Based on observation of Patient #5 in a 4 point restraints and review of facility policy and procedure, it was determined that the facility failed to implement its policy and procedures pertaining to restraints.

Findings include:

Reference: Facility policy titled, "Restraint/Seclusion For Behavioral Management: Special Treatment Procedures" states, "...Application of Restraints...Remove the patient's shoes, socks, hair decorations..."

1. During a tour of the West Unit on 9/4/19, the following was revealed:

a. At 12:43 PM, Patient #5 was in 4 point restraints, wearing socks on both feet.

b. Staff #17 failed to remove Patient #5's socks, in accordance to facility policy.

Based on observation, staff interviews, and review of facility documentation, it was determined that the facility failed to maintain a quality assessment and performance improvement program that accurately tracks adverse events to analyze their causes, implements preventative actions, and implements polices and procedures for patient safety.

Findings include:

1. The facility failed to ensure it accurately documents its adverse patient events, to ensure tracking and analysis for its Quality Assessment and Performance Improvement activities. (Cross refer to Tag A 286)

2. The facility failed to ensure that environmental risk Quality Assessment and Performance Improvement assessments are conducted to determine what environmental risks exist. (Cross refer to Tag A 701)

Based on staff interviews and review of facility documents, it was determined that the facility failed to conduct performance improvement activities to reduce patient falls in accordance with their quality assurance performance improvement plan.

Findings include:

Reference #1: Facility Policy and Procedure, The Performance Improvement Plan and Reporting states, "... 5. The QAPI Committee will meet on a monthly basis to review all QAPI audits. ... Performance Improvement Plan, Specific Performance Improvement Council Responsibilities include: ...10. Use comparison data to benchmark, 11. Document findings, conclusion, recommendations and actions in meeting minutes. ...Cycle for Improving Performance, Cornerstone Behavioral Health Hospital utilizes the Plan, Do Check, and Act (PDCA) model to improve performance. ...Check, Aggregate data and compare results to predictions. Act: Return to the Plan phase of the PDCA cycle if modification in the process are required as the result of data assessment. Formalize processes determined to be effective through: The development of policies and procedures; and/or, The creation and/or revision of programs. ...Summary: (PLAN) Our approach to Performance Improvement will always be planned, systematic and organization wide. ..."

1. Upon review on 9/4/19, the monthly QAPI meeting minutes and data dated April, May, and June 2019 showed no evidence of:

a. Using comparison data to benchmark for patient falls prevention in accordance with the facility QAPI plan.

i. The QAPI meeting minutes and data dated June 2019 did not include a benchmark for patient falls.

b. Comparing data results for all patient falls in accordance with the facility QAPI plan.

i. The QAPI meeting minutes and data dated June 2019 did not have comparison data on patient falls.

c. Providing an organizational-wide QAPI plan to reduce patient falls.

i. The "Fall Report Summary" dated 6/2019 documented that three patients falls occurred in the month of June and the entries recorded: 1). patient fell while in the courtyard, 2) patient fell while trying to sit on the bed, and 3) patient fell while going to the toilet. The analysis included interventions for each patient: 1). medication adjustments, 2) OT services for therapeutic exercises, and 3) continued use of rolling walker for ambulation.

ii. The QAPI meeting minutes dated June 2019 did not include an organization-wide plan to reduce patient falls for the month of June 2019.

iii. The QAPI meeting minutes dated June 2019 states under recommendations, "...7. UR Nurse reviewed and submitted a detailed report on all listed QAPI topics." On 9/4/19 at 12:00 PM, Staff #11 confirmed that he/she completed reports to monitor patient falls as listed under recommendations of the QAPI committee for June 2019. There were no other recommendations noted under patient falls on the QAPI meeting minutes dated June 2019.

2. On 9/4/19 at 12:00 PM, Staff #5 stated, almost every patient admitted to their facility is a fall risk... . Interventions are put in place at the time of a fall for each specific patient. One additional intervention has been initiated, which is to add a group activity to the patient schedule at change of shift.

a. Staff #5 could not recall what the group activity is or when the group activity was initiated.

b. Review of the QAPI meeting minutes dated May, April and June 2019 did not reflect the addition of the change of shift activity.

c. There was no documented evidence the change of shift activity was being monitored.

d. The above was confirmed with Staff #5 and Staff #11.

Based on observation, staff interview, medical record review and review of facility documents, it was determined that the facility failed to ensure that individualized care plans are implemented.

Findings include:

Reference #1: Facility policy Fall Prevention/ Falls, states, " ... Admission 1. Complete the nursing assessment including the Fall Risk Assessment. ...Interdisciplinary Team 1. Review completed Fall Risk Assessment on Interdisciplinary Admission Assessment..."

Reference #2: Facility policy Interdisciplinary Master Treatment Plan (MTP), states, "...4. ...The specific problem treatment plans Form(s) #213-020 (C-M) will be developed and updated/revised as necessary at least every 7 [seven] days..."

1. Patient #1 was admitted to the facility on 6/21/19 and was a current patient during this survey. On 9/3/19 at 12:15 PM a review of Medical Record #1 revealed the following:

a. The Fall Risk Assessment dated 6/21/19 documented that the patient's total score was "9 [nine]". A score of 10 [ten] or higher indicates a, "High Risk".

(i) The documented assessment of History of Falls (Past 3 months) states, " ... pt refused to answer ..." The record did not indicate that staff reviewed prior medical history or obtained information from the patient's family or significant other.

(ii) During an interview on 9/3/19 at 12:35 PM, Staff #22 stated that the fall risk should have been re-evaluated with information obtained from past medical records and information from the patient's family. Staff #22 confirmed that there was no re-evaluation of the patient's fall risk since 6/21/19.

b. The Interdisciplinary Progress Note dated 6/21/19 at 1:00 PM states, " ... High Risk for fall [secondary to] poor balance when turn [sic] ..."

c. The Admission Nursing Treatment Plan dated 6/21/19 indicated that a Fall Precaution plan was identified with a target date of 6/24/19.

d. Medical Record #1 lacked evidence of an update to the plan, as required by facility policy.

Based on medical record review and staff interview, it is determined that the facility failed to maintain accurate medical records.

Findings include:

1. Review of Medical Record #6 on 9/4/19 revealed the following:

a. On a Physician Order sheet, "NKDA" (no known drug allergy) was hand written in the section marked "allergy."

i. On the MAR (medication administration record), Haldol and Latex was listed as an allergy.

ii. On 9/4/19, Staff #22 stated, "We forgot to change that."

2. This finding was confirmed with Staff #22.

Based on observation, staff interviews and document review, it was determined that the facility failed to ensure the development and implementation of policies and procedures that discontinued medications are returned to the provider pharmacy.

Findings include:

Reference: The NEW JERSEY ADMINISTRATIVE CODE TITLE 13 LAW AND PUBLIC SAFETY CHAPTER 39 STATE BOARD OF PHARMACY states: "... SUBCHAPTER 9 PHARMACEUTICAL SERVICES FOR HEALTHCARE FACILITIES ... 13:39-9.8 CONTROL OF HEALTH CARE PHARMACEUTICAL SERVICES; RESPONSIBILITIES OF THE PHARMACIST-IN-CHARGE OF THE PROVIDER PHARMACY "...c) The pharmacist-in-charge of the provider pharmacy, with the cooperation of the Pharmacy and Therapeutics Committee, shall develop written policies and procedures as needed to provide pharmaceutical services to the facility."

1. Upon request on 9/4/19, the facility failed to provide policies and procedures addressing returning discontinued medications back to the provider pharmacy.

2. During an observation conducted 9/4/19, in the Medication Room in West Unit, the content of medications for Patient #12 was compared with the Medication Administration Record. The following discrepancy was revealed:

a. One bottle of Flonase Nasal Spray labeled "Opened 8/27/19" was found in the medication cabinet. The medication was dispensed on 8/26/2019.

(i) The Medication Administration Record revealed that the Flonase Nasal Spray was ordered on 8/26/19, with the direction of "2 sprays each nares qd (once a day) for 1 week."

b. One bottle of Flonase Nasal Spray labeled "Opened 6/29/19" was found in the medication cabinet. The medication was dispensed on 6/28/2019.

(i) The Medication Administration Record revealed that the Flonase Nasal Spray was ordered on 6/28/19, with the direction of "2 sprays each nostril daily for 7 days."

3. During an observation conducted 9/4/19, in the Medication Room in West Unit, the content of medications for Patient #14 was compared with the Medication Administration Record. The following discrepancy was revealed:

a. One bottle of Saline Nasal Spray labeled "Opened 7/10/19" was found in the medication cabinet. The medication was dispensed on 7/9/2019.

(i) The Medication Administration Record revealed that the Saline Nasal Spray was ordered on 7/1/19, with the direction of "one spray to each nostril four times daily as needed for congestion." The order was discontinued on 7/11/19.

b. One bottle of Flonase Nasal Spray labeled "Dispensed 6/17/19 and Opened 6/19/19" was found in the medication cabinet. Upon interview, Staff #22 stated that there is no current order for Flonase Nasal Spray and the medication should have been returned to pharmacy.

4. This finding was confirmed by Staff #1, Staff #2, Staff #3, and Staff #4.

Based on observation, staff interviews, and document review, it was determined that the facility failed to ensure that drug storage areas are under competent supervision.

Findings include:

1. During an observation on 9/5/19, in the medication room in East Unit, the following insulin products were stored in the medication refrigerator:

a. One vial of Novolin-N, labeled with a dispense date of "7/22/19"

b. One vial of Novolin 70/30, labeled with a dispense date of "7/22/19"

c. One vial of Novolin 70/30, labeled with a dispense date of "4/23/18"

2. Review of the medication refrigerator temperature log for the month of July, 2019, indicated the following:

a. 60 degrees Fahrenheit AM and PM on 7/18/19

b. 60 degrees Fahrenheit AM on 7/19/19

c. Out of Order on 7/20/19, 7/21/19 and 7/22/19

d. The temperature log states, "Please notify FSD [Facility Service Director] when temps [temperatures] are above 40 degrees."

e. Upon interview, Staff #28 was not aware that the refrigerator had been out of order.

f. At the time of the survey, Staff #4 was not able to provide evidence that a pharmacist was contacted on the days that the medication refrigerator had been out of range.

g. Upon request, facility was not able to provide policies and procedures addressing medications stored outside the recommended temperature range.

3. The above findings were confirmed by Staff #1, Staff #2, and Staff #4.

A. Based on observation, staff interviews, and document review, it was determined that the facility failed to ensure implementation of policies and procedures addressing disposal and wasting of controlled substances.

Findings include:

Reference: Facility policy titled "Controlled Substances" states, "Procedure: ...II. Documentation of Controlled Substance Procedure: B. ...When Controlled Substances are administered, the nurse will note on the CDAR [Controlled Drug Administration Record]: ...Dose/amount wasted-signature of the two nurses wasting the medication ...IV. Ordering of Stock Controlled Substance: ...B. Disposal of Controlled Substances-stock: 1. Outdated or unwanted, contaminate stock controlled substances that require destruction, Medical Director's Office is notified."

1. Review of the Housestock West Control Countdown sheet dated, 2/19/19 for Lorazepam 2 mg (milligram) /ml (milliliter) injection, the following was identified:

a. On 8/23/19, it was recorded that one (1) vial of Lorazepam 2 mg/ml, "bottle cracked and wasted."

b. Upon interview, Staff #29 confirmed that he/she did not notify the Medical Director's Office.

2. Review of the Housestock West Control Countdown sheet dated, 7/12/19 for Lorazepam 2 mg (milligram) /ml (milliliter) injection, the following was identified:

a. On 7/21/19, it was recorded that two (2) vials of Lorazepam 2 mg/ml were refused by Patient #23 and the vials had been wasted. The record lacked signatures of two nurses wasting the medication.

b. The above findings were confirmed by Staff #1, Staff #2, Staff #3, and Staff #4.

B. Based on document review and staff interview, it was determined the the facility failed to ensure implementation of policies and procedures addressing the receipt of controlled substances.

Findings include:

Reference: Facility policy, Controlled Substances states, "Procedure: I. Controlled Substances Orders and Receipt: ... 2. The Unit Nurse will review each medications received and compare the 203.138D Individual Patient's Controlled Drug Record for accurate medication, number received and documentation of information. The pharmacy's 203.138F Packing Slip Pharmacy Provider-will be signed by the Unit Nurse for receipt of medications."

1. Review of Individual Patient's Controlled Drug Record, dated 8/22/19 for Patient #5, revealed that 21 tablets of Lorazepam 1 mg tablets were received by the facility.

a. The columns indicating the "Signature of Nurse Receiving Drug," "Date Received," and "Amount Received" were blank.

2. The above finding was confirmed by Staff #1, Staff #2, and Staff #4.

Based on observation, staff interview, and review of manufacturer's instructions for use, it was determined that the facility failed to ensure that unusable drugs are not available for patient use.

Findings include:

Reference: Medline Sterile Water Manufacturer's Instructions for use states, "Indications: ...Caution: ... No antimicrobial or other substance added ... Contents sterile unless container is opened or damaged ..."

1. On 9/3/19 at 10:55 AM, during a tour of the Treatment Room on the West Unit, in the presence of Staff #17, the following was observed:

a. A half-empty bottle of "Medline Sterile Water" was located on a counter next to a sink. There was no label indicating a patient's name or the date the bottle was opened.

(i) Staff #17 explained that the sterile water is used by nursing personnel for wound care and dressing changes on patients and should be used only on one patient and should be labeled with the patient's name and date the bottle was opened.

2. There was no indication of how long the bottle had been open and if it was dedicated for use on one or multiple patients.

Based on observation, staff interviews and document review, it was determined that the facility failed to provide organized dietary services that maintain at least the minimum standard specified in this section.

Findings Include:

1. The Food Services Director failed to ensure the daily management of the dietary service. (Cross refer to Tag A620)

A. Based on staff interview, it was determined that the facility failed to provide the qualifications of the Food Service Director.

Findings include:

1. Upon request on 9/3/2019 at 11:00 AM, Staff #2 was unable to provide credentials for the food service director or a contract for the actual services provided.

2. The above findings were confirmed by Staff #2.

B. Based on observation, staff interviews, policies and procedures review, and review of the New Jersey State Sanitary Code, Sanitation in Retail Food Establishments and Food and Beverage Vending Machines, (NJAC 8:24), it was determined that the facility failed to ensure responsibility for the daily management of the Food Service Department.

Findings include:

Reference #1: Food Service Director's job description states, "... Position Summary: The Food Service Director establishes, maintains, and improves the overall production quality and performance of the operations of the Dietary department...Part 1: Job Responsibilities and Standards...1. Responsible for quality monitoring of all aspects of food production and service. ...3. Responsible for implementing and supervising sanitation audits."

Reference #2: N.J.A.C. 8:24-6.5(a) states, "The physical facilities shall be maintained in good repair."

Reference #3: N.J.A.C. 8:24-6.5(b) states, "The physical facilities shall be cleaned as often as necessary to keep them clean."

Reference #4: N.J.A.C. 8:24-6.5(i), states, "Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be stored: 1. So that they do not contaminate food, equipment, utensils, linens, and single-service and single-use articles."

Reference #5: N.J.A.C. 8:24-6.5(j) states, "The premises shall be free of items that are unnecessary to the operation or maintenance of the establishment such as equipment that is non-functional or no longer used, and litter."

Reference #6: N.J.A.C. 8:24-4.8(k) states, "A test kit or other device that accurately measures the concentration in mg/L of sanitizing solutions shall be provided." 8:24-4.8(i) states, "Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device."

Reference #7. The facility policy titled, "Pot Washing Policy" states, "4. Test 3rd sink for proper sanitizing solution with test strip...10. Air dry all clean and sanitized pots and wares. Do not wipe dry."

Reference #8: N.J.A.C. 8:24-4.11(2) states, "Clean equipment and utensils shall be stored: (i) In a self-draining position that allows air drying; and (ii) Covered or inverted."

Reference #9: The facility policy titled, "Personal Hygiene Policy" states, "...3. Cover all hair with restraint (hairnet, cap or hat).

Reference #10: The facility policy titled, "Perishable Foods policy" states, "...6. All food securely covered, dated and labeled."

Reference #11: The facility policy Receivable and Storage states, "5. Store all items at least 6 inches off the floor, 18 inches from the ceiling and away from refrigerator, freezer, and dry storage area walls. "

Reference #12: The facility policy Cold Food, states, "2. Food will be stored at a temperature of 40 degrees or lower."

Reference #13: N.J.A.C. 8:24-6.7(j) states, "Each handwashing sink or group of adjacent sinks shall be provided with the following: 1. Individual, disposable towels."

1. During a tour of the main kitchen on 9/3/2019 at 10:30 AM, in the presence of Staff #9 and Staff #14, the following observations were made:

a. Two (2) corner floor tiles at the entrance of the ware washing room were broken. (Refer to reference #1, and #2)

b. Upon entering the kitchen, hair restraints were unavailable in the hair restraint receptacle. (Refer to reference #9)

(i) Upon interview, Staff #9 stated that the hair restraint receptive should have been refilled.

c. The hand washing sink next to the ice machine failed to have paper towels. (Refer to reference #13)

d The hand washing sink near the storage area failed to have paper towels. (Refer to reference #13)

(i) Upon interview on 9/3/2019 at 10:40 AM, Staff #10 stated, "We rarely use this sink".

e. A second ware washing machine, referred to as machine #2 by Staff #15. During interview on 9/3/2019 at 10:45 AM, Staff #15 and Staff #16 confirmed that it was not in functional condition.

(i) There was no signage on the ware washing machine indicating that it was not functional and out of service. (Refer to reference #2 and #5)

(ii) Refrigerator #5 was out of service. There was no signage on Refrigerator #5 indicating it was out of service. (Refer to reference #2 and #5)

f. The Rolling Refrigerator Protek 4092 had a red bucket collecting water through a pipe next to it.

(i) Upon interview on 9/3/2019 at 11:30 AM, Staff #15 stated that the refrigerator had a leak, and therefore a bucket was placed to collect water from the leak. (Refer to reference #2 and #5)

(ii) The Rolling Refrigerator contained five (5) trays of prepared salads lacking dates 'prepared' or 'use by date' labels. (Refer to reference #10)

g. The meal service tray line near the coffee making station contained a red bucket collecting water under. (Refer to reference #2 and #5)

(i) During interview on 9/3/2019 at 11:35 AM, Staff #10 was unable to identify the source of the leak. or provide a repair order.

(ii) Upon request, Staff #10 was unable to provide a repair order.

h. The temperature on the refrigerator next to the meal service tray line was 58 degrees Fahrenheit. (Refer to reference #12)

(i) Upon checking the internal temperature of a four (4) ounce health shake container from the refrigerator next to the meal service tray line, it was 56 degrees Fahrenheit.
(Refer to reference #12)

(ii) The door of the refrigerator had torn gaskets, preventing a proper seal of the door. (Refer to reference #2)

i. The walk-in refrigerator #2 had torn doorway sweeps. (Refer to reference #2)

(i) A leak from the compressor area was wrapped with a white cloth. (Refer to reference #5)

(ii) Upon interview on 9/3/2019 at 11:15 AM, Staff #15 stated that the white towel was wrapped to absorb water leakage.

(iii) The right side floor of walk-in refrigerator #2 had visible water puddles and orange-brown discoloration.

(iv) During interview on 9/3/2019 at 11:15 AM, Staff #15 stated that the food racks had been moved to the left side of the refrigerator due to the water accumulation.

j. During interview on 9/3/2019 at 11:15 AM, Staff #10 was unable able to explain how much water with sanitizer is used for pot washing. (Refer to reference #6)

(i) The pot washing area failed to have a test kit or other device to accurately measure the concentration of the pot washing sanitizing solution. (Refer to reference #6)

k. Two (2) racks, filled with cleaned wet pots and pans, were stacked on top of each other, not allowing them to air dry. (Refer to reference #7)

l. The white freezer next to refrigerator #5, located across from the meal service tray line, had a thick layer of ice accumulation. (Refer to reference #2)

(i) During interview on 9/3/2019 at 11:15 AM/, Staff # 15 stated that the freezer needed defrosting.

n. Wet mops and dirty brooms were placed on the floor of the Utility closet (Refer to reference #4)

o. The storage area for emergency supplies contained boxes touching the ceiling. (Refer to reference #11)

2. During a tour of the patient unit - East on 9/4/2019 at 11:00 AM, in the presence of Staff #10, the following was observed:

a. The microwave in the patient pantry had visible brown debris on the inside roof and glass plate. (Refer to reference #3)

b. The refrigerator in the patient pantry had unlabeled food items. (Refer to reference #10

(i) During interview on 9/4/2019 at 11:10 AM, Staff #10 stated that the unlabeled food items belonged to staff. (Refer to reference #10)

3. The above findings were confirmed with Staff #1, Staff #2 and Staff #10.

Based on staff interview and review of facility documents, it was determined that the facility failed to ensure the Utilization Review (UR) Committee included members of the medical staff.

Findings include:

The facility failed to ensure that there were two independent physicians on the UR Committee. (Cross refer to Tag 654)

Based on staff interview and document review, it was determined that the facility failed to ensure that the Utilization Review (UR) Committee consisted of two independent physicians, regularly attending the UR committee meetings.

Findings include:

1. On 9/4/19, the Utilization Review Committee meeting minutes dated 10/17/18, 1/23/19 and 7/17/19 were reviewed. Documented evidence showed only one independent physician attended the UR committee meetings.

2. During interview on 9/4/19 at 2:00 PM, Staff #11 confirmed that they do not have two independent physicians attending the UR committee meetings.

Based on observation and staff interview, it was determined that the facility failed to provide a safe setting that is appropriate for the special needs of the patient population.

Findings include:

1. The facility failed to ensure a safe environment that is appropriate for the special needs of the patient population.(Cross refer to Tag A 701)

Based on observation and staff interviews, it was determined that the facility failed to ensure the hospital environment is developed and maintained to ensure that all patients are safeguarded from potential harm.

Findings include:

1. On 9/4/19 at 11:00 AM in the presence of Staff #27, the following safety concerns were identified during a tour of the facility:

a. Light fixtures on the wall above the head of twenty (20) of twenty (20) patient beds located on the East Wing were equipped with one half inch metal bands that extended from the top of the light fixture and extended around the front of the fixture to the underside. These bands provided an approximate on half to one inch space that would provide a ligature point. Each of the twenty (20) light fixtures were equipped with (3) of these metal bands.

i. During interview, Staff #27 stated the following, "the bands were installed to prevent the patients from accessing the lenses, light bulb, and live electrical socket".

ii. Staff #27 confirmed, the metal bands around the light fixtures were unmitigated ligature risks.

g. Staff #27 also confirmed that no environmental risk assessment has ever been conducted to determine what environmental risks exist.


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2. On 9/3/19 at 11:40 AM in the presence of Staff #17, large accumulations of dust was found on the top of closets in Patient Rooms #CW68, #CW80, and #CW84.

3. On 9/3/19 at 11:30 AM in the presence of Staff #17, a blue colored residue was found on the shower heads and a white residue was found on the shower curtains located in Patient Bathrooms #2 and #3.

Based on observation and staff interviews, it was determined that the facility failed to ensure that the emergency code cart contained all necessary supplies to ensure an acceptable level of safety and quality.

Findings include:

1. During an observation on 9/4/19, in the emergency code cart for the East Unit, two (2) suction catheter Tray with Chimney Valve was found expired on 8/21/19.

2. The above finding was confirmed with Staff #1, Staff #2, and Staff #4.

Based on observation, staff interviews, review of facility documents and nationally recognized guidelines, it was determined that the facility failed to ensure the provision of a sanitary environment and implement an adequate Infection Control program that seeks to minimize infections and communicable diseases in accordance with the nationally recognized infection control guidelines it has selected for its program.

Findings include:

1. The facility failed to ensure that an Infection Control Professional (ICP) was designated to oversee the infection prevention and control program. (Cross refer to Tag A 748)

2. The facility failed to provide a functional and sanitary environment by adhering to professionally acceptable standards. (Cross refer to Tag A 749)

3. The facility failed to provide the Manufacturer's Instructions for Use (IFU) for cleaning and disinfecting the Ultra Trak Pro Glucometer. (Cross refer to Tag A 749)

4. The facility failed to ensure development and implementation of policies and procedures for cleaning and disinfecting the Ultra Trak Pro Glucometer. (Cross refer to Tag A 749)

Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that a qualified Infection Control Professional (ICP) was designated to oversee the facility's Infection Control Program.

Findings include:

1. On 9/3/19 at 10:37 AM, during the entrance conference, Staff #1 and Staff #2 confirmed that the facility's ICP retired, and the facility does not have a current ICP to oversee the facility's Infection Control Program.

a. The personnel file for Staff #6, the retired ICP, was reviewed. The file contained a letter of resignation dated 6/18/19, with the last day of work being 7/31/19.

b. Staff #1 and Staff #2 stated that until a new ICP takes over, they are both acting as ICP's for the facility.

2. Personnel file review failed to show evidence of additional Infection Control Preventionist Training.

3. Staff #1 and Staff #2, Administrative staff, confirmed that neither of them have Infection Control Training.

A. Based on observation, staff interview, review of facility documents and CDC (Center for Disease Control) guidelines, it was determined that the facility failed to ensure that the Infection Control Program has adequately implemented CDC guidelines, to prevent infections and communicable disease during Glucose Monitoring.

Findings include:

Reference: CDC website: http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html titled "Infection Prevention during Blood Glucose Monitoring and Insulin Administration" states, "...Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared."

1. On 9/3/19 at 10:00 AM, during the entrance conference Staff #1 and Staff #2 confirmed that the facility's Infection Control program is based on CDC guidelines.

2. On 9/3/19 at 1:30 PM, on the CSE (Cornerstone East) unit, Staff #23 stated that the facility uses the Ultra Trak Pro glucometer for Blood Glucose Monitoring of patients. Upon interview, Staff #23 stated that after patient use, the glucometer is cleaned and disinfected with either an alcohol pad or a PDI Super Sani Cloth wipe.

(i) The Manufacturer's Instructions for Use (IFU) for the Ultra Trak Pro glucometer was requested and not received.

3. On 9/3/19 at 1:50 PM, on the CSW (Cornerstone West) unit, Staff #22 stated that the facility uses the Ultra Trak Pro glucometer for Blood Glucose Monitoring of patients. Upon interview, Staff #22 stated that after patient use, the glucometer is cleaned and disinfected with a papertowel.

(i) The Manufacturer's IFU for the Ultra Trak Pro glucometer was requested and not received.

4. On 9/3/19 at 2:00 PM, on the CSW (Cornerstone West) unit, Staff #17 stated that after blood glucose monitoring, the glucometer is cleaned and disinfected with a 4x4 gauze sponge moistened with tap water.

5. On 9/4/19 at 10:00 AM, on the CSW (Cornerstone West) unit, Staff #22 confirmed that there were two (2) patients on the CSW unit that were receiving glucose monitoring.

(i) At 11:53 AM, Staff #22 was observed performing blood glucose monitoring on Patient #7, using the Ultra Trak Pro glucometer. After the completion of the monitoring, Staff #22 failed to clean and disinfect the glucometer, prior to placing it back in the pouch and in the cabinet in the medication room.

(ii) Upon interview, Staff #22 confirmed he/she did not clean and disinfect the glucometer after patient use and that the glucometer is used for multiple patients.

On 9/4/19, at Staff #2 was notified that the above findings resulted in an Immediate Jeopardy (IJ) and a completed copy of the IJ template was provided on 9/4/19

On 9/5/19, an acceptable removal plan was received.

B. Based on observation and staff interview, it was determined that the facility failed to provide a sanitary environment to avoid sources of infections and communicable disease.

Findings include:

1. On 9/3/19 at 11:30 AM, in patient room E020, the following was observed:

a. The mattress on the bed closest to the door was torn at the seam along the side of the mattress, exposing the material underneath, making it an uncleanable surface.

b. The following unlabeled personal items were observed in the bathroom:

- Two (2) containers of shampoo
- Two (2) containers of lotion
- One (1) toothbrushes
- One (1) tube of toothpaste
- A small plastic container with dentures

(i) Upon interview, Staff #23 stated that room E020 was a semi-private room and the bathroom is shared by the two (2) patients staying in room E020. Staff #23 confirmed that the personal items listed above belonged to the two (2) patients and should have been labeled to distinguish between the two (2) patients personal property.

2. On 9/4/19 at 11:05 AM, in the medication room on the CSW unit, there was a refrigerator that contained patient medications. The white racks inside the refrigerator contained a brown discoloration with rough surfaces, rendering it an uncleanable surface.

3. The above findings was confirmed with Staff #2.


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4. On 9/3/19, a white Styrofoam cup was noted in the pantry refrigerator, on the door.

a. The Styrofoam cup contained a white liquid. The cup was open to air and unlabeled.

b. In the Seclusion room, the mattress contained brown and brownish red residue on the bottom.

c. In the laundry room, two bundles of clean facility towels were stored on a shelf.

(i) Patient belongings were store among clean facility towels.

(ii) Staff #17 confirmed that the laundry room is not a patient belongings designated area and that patient belongings can potentially contaminate the clean towels.

d. In the Treatment room, the following was observed:

i. A gallon jug of Distilled Water was opened and failed to have an "open" date.

ii.. Upon interview on 9/3/19 at 10:55 AM, Staff #17 stated, "If we open it, we put a date when it's open. It's only good for 28 days."

iii. The treatment table drawer contained brown residue.

e. The mattress in room CW68B was soiled with urine.

i. There was a pool of urine in the base of the bed.

ii. These findings were confirmed with Staff #17.

C. Based on observation, interview, and review of facility policy, it was determined that the facility failed to provide a sanitary environment by following hand hygiene guidelines to reduce the transmission of communicable diseases.

Findings include:

Reference: Facility policy titled, "Hand Hygiene/Hand -Washing" states, "All employees will adhere to the Center for Disease Control (CDC) guidelines regarding hand hygiene to reduce the transmission of pathogenic organisms... Indications for handwashing and hand antisepsis... Before and after giving patient care or performing procedure..."

1. During a tour of the West unit on 9/4/19 at 12:48 PM, the following was observed:

a. Staff #17 participated in the restraining process of Patient #5.

i. Staff #17 failed to perform hand hygiene following the application of the restraint.

This Condition is not met as evidenced by:

Based on record review and interview, the facility failed to:

I. Ensure that collaborative Master Treatment Plans (MTPs) developed included measurable goals (refer to B121), patient problem-specific interventions were included (refer to B122), and that the MTPs were modified as needed (refer to B122).

II. Ensure active treatments, including alternative treatments, were provided to patients who are unable or unwilling to participate in routine unit program activities. (refer to B125)

III. Provide for a Qualified Director of Nursing. (refer to B147)

Based on record review and interview it was determined for eight (8) of eight (8) active sample (A1,A2,A3,A4,A5,A6,A7 and A8 ) patients, the facility failed to perform and document a comprehensive physical examination including neurological examinations in such a way as to verify specific tests performed. Instead, the facility used pre-printed "KNJ Hospitalist Group, History and Physical" forms which included similar exams and results pre-printed to all patients. This failure precludes the identification of continuing pathology or sequelae which may be pertinent to a patient's present mental illness and thereby potentially adversely affecting patient care.

Findings include:

a. Record review:

Active sample patients' A1(7/19/19), A2 (8/15/19), A3 (8/7/19), A4 (8/22/19), A5 (7/30/19), A6 (8/13/19), A7 (8/6/19) and A8 (8/16/19) "History and Physical" forms (dates of the examinations in parenthesis) were reviewed. All of the 8 sample patients' physical examinations' results were similarly preprinted including "Neurologic" examinations. As none of the exams or results were modified or checked off by the examining physicians, it is impossible to determine if any examinations were performed at all. The preprinted Neurological exam results for all of the 8 active sample patients were similar, "Cranial nerves II - XII grossly intact. Sensory intact bilaterally. Motor 5/5 in upper and lower extremities. Deep tendon reflexes downward going[sic]." There was no documentation regarding any tests performed and how these examination results were arrived at.

b. Staff interview:

In a meeting with the Medical Director on 9/4/19 at 10:30 a.m., the above deficient practices regarding the "History & Physical" examinations were reviewed, and he did not dispute the findings.

Based on document review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patients' personal assets in a descriptive fashion for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The facility uses pre-printed forms with similar patient assets selected for most patients or none selected at all. This failure to identify patient's personal assets impairs the treatment team's ability to choose treatment modalities that utilize a patient's assets in therapy.

Findings include:

a. Record Review

1. Psychiatric evaluations (dates in parenthesis) of patients A1 (7/19/19) and A2 (8/15/19) had no "patient assets and strengths"identified/documented.

2. Psychiatric evaluation (date in parenthesis) of patient A3 (8/6/19) had "Physical health" as "patient assets and strengths" identified/documented.

3. Psychiatric evaluation (date in parenthesis) of patients A4 (8/21/19) had "cooperative" as "patient assets and strengths" identified/documented.

4. Psychiatric evaluations (dates in parenthesis) of patients A5 (7/30/19), A6 (8/12/19), A7 (8/15/19) and A8 (8/15/19), all had "Housing" and "Family" as "patient assets and strengths" identified/documented.

b. Document Review

The facility's Policy and Procedures "213 - 106 - "Admission Process: Initial Psychiatric Assessment, History And Physical, Orders, Progress Notes" (last "Date Revised: 9/22/17) states, under "Procedure: Include an inventory of the patient's assets in descriptive, not interpretive fashion. The assets that describe personal factors on which to base the treatment plan or which are useful in therapy represent personal strengths."

c. Interview

In a meeting and review of the above deficiencies on 9/4/19 at 10:30 a.m., the Medical Director did not dispute the above noted deficiencies.

Based on Record review and Staff interview, the facility failed to develop Master Treatment Plans (MTP) that identified patient-centered Short-Term Goals (STGs) stated in observable, measurable, behavioral terms for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The facility uses pre-printed forms and many of the identified goals were similar for all patients and appear to be staff expectations rather than patients' problem-specific goals to be accomplished. This lack of patients' problem-specific goals hampers the treatment team's ability to assess changes in patients' conditions as a result of treatment interventions and may contribute to failure to modify plans in response to patients' needs.

Findings include:

Medical Record Review:

1) Patient A1 admitted on 7/18/19 with a diagnosis of "Bipolar disorder, manic with psychotic features," had listed on MTP dated 7/19/19 for the Problem, "Mood Disorder," as evidenced by Hx hallucinations, Delusions as evidenced by believing in exorcism, voodoo and hypnosis, Non adherence to Medications, Agitation as evidenced by anxiety, poor ADLs as evidenced by not caring for self.", had the following STGs: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will be free from thoughts of self harm (not identified as a problem behavior), disorganization of thoughts, anxiety and thoughts of exorcism, voodoo and hypnosis. 4. Patient will attend all groups for 45 minutes daily with relevant participation. Some of the identified goals appear to be staff expectations rather than addressing the patient's problem-specific behaviors.

2) Patient A2, admitted on 8/14/19 with a diagnosis of "Schizoaffective disorder B/T[Bipolar Type]," had listed on the MTP (Master Treatment Plan), dated 8/15/19, for the Problem, "Altered Thought, as evidenced by elevated - anxious mood, spending long periods in [her/his] room, delusions about ghosts + auditory hallucinations..", the following STGs: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will be free from Risk of injury. 4. Patient will attend all groups for 30-45 minutes daily with relevant participation." The identified goals appear to be staff expectations rather than measurable patient behaviors to be achieved.

3) Patient A3, admitted on 8/6/19 with a diagnosis of "Schizophrenia," had listed on MTP dated 8/7/19 for the Problem of "Altered Thought" "as evidenced Responding to internal stimuli, Non-adherence to Medication Because decompensate [sic]?, Agitation as evidenced by becoming aggressive towards family," the following STGs: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will be free from paranoia delusional [sic]?, be able to express adherent [sic]? needs, behavior will be in control 100% of the time. Patient will not expose [him/her] self while on the unit or in public. 4. Patient will attend all groups for 45 minutes daily with relevant participation." Some of the identified goals appear to be staff goals rather than addressing patient's problem behaviors. In addition, the goals identified are not measurable.

4) Patient A4, admitted on 8/21/19 with a diagnosis of "Schizophrenia, paranoid type, Cannabis use do[sic]" had listed on MTP dated 8/22/19 for the Problem, "Altered Thought," "Hallucinations as evidenced by "I see blood, swords cutting people[sic]? heads off, history of non-compliance, poor insight into illness as evidenced by frequent readmissions in the past year, sexual preoccupation," the following STGs: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will attend all groups for 45 minutes daily with relevant participation." The identified goals appear to be staff goals rather than addressing the patient's problem behaviors.

5) Patient A5, admitted on 7/30/19 with a diagnosis of "Schizophrenia paranoid type rule out schizoaffective disorder," had listed on MTP dated 7/30/19 for the Problem, "Altered Thought" "Hallucinations as evidenced by God talking to [her/him]..., Thought Disorder as evidenced by -difficult to understand, aggression, poor insight - not taking medication and non-compliance, Religious preoccupation...., Agitation- hx. Attacking psychiatrist.. other patients' children," the following STGs: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will be free from hallucinations, impulsive aggressive behavior, low frustration tolerance. 4. Patient will attend 2-3 groups for 20 minutes daily with relevant participation." The identified goals appear to be expectations of staff for the patient and are not measurable behaviors for the patient to achieve.

6) Patient A6, admitted on 8/12/19 with a diagnosis of "Schizophrenia disorganized, Cannabis abuse," had listed on MTP dated 8/13/19 for the Problem, "Altered Thought" "Delusions as evidenced by the state is going to [him/her] a house [sic]?, Thought disorder as evidenced by pt. found wandering the streets, lost. Poor insight into illness as evidenced by frequent hospitalizations," the following STGs: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will be free from auditory hallucinations, paranoid ideations, delusional thoughts. 4. Patient will attend 2-3 groups for 30 minutes daily with relevant participation." The identified goals appear to be staff goals rather than addressing the patient's problem behaviors and neither behaviorally stated nor measurable.

7) Patient A7, admitted on 8/15/19 with a diagnosis of "Schizophrenia- Paranoid" had listed on MTP dated 8/19/19 for the Problem, "Altered Thought" "Hallucinations as evidenced by talking aloud to John Mcgod, bizarre movements...taking others belongings, refusing scheduled medications, agitation, pacing, loud, disruptive, spitting at staff...", the following Short Term Goal [STG]: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will be free from auditory hallucinations, wandering and taking others belongings, aggressive behaviors, spitting at peers and staff. Non-compliance with medications." 4. Patient will attend 2-3 groups for 30 minutes daily with relevant participation." The identified goals are staff goals and are not measurable.

8) Patient A8 admitted on 8/15/19 with a diagnosis of "Schizophrenia, Cannabis use d/o, Tobacco use d/o." had listed on MTP dated 8/16/19 for the Problem, "Altered Thought" "Hallucinations as evidenced by telling [him/her] not to eat, not go outside, not to shower, med non-compliance, social withdrawal." The Psychiatric Assessment of 8/16/19 also states "Mother called to report increased paranoia, hallucinations, attempts to harm self by cutting him/herself with a knife. His/her mother had to take the knife out of his/her hands." The following STGs were listed: "1. Patient will accept medications 100% of the time and state two (2) benefits of use. 2. Patient will be in behavioral control 100% of the time. 3. Patient will be free from paranoid ideation, auditory hallucinations "not to shower, not to eat, suicidal ideation that he/she will be shot if he/she goes outside." 4. Patient will attend 2-3 groups for 30 minutes daily with relevant participation." The identified goals appear to be expectations of the staff for the patient and are not measurable behaviors for the patient to achieve.

In an interview with Medical Director on 9/5/19 at 10:30 a.m., the above deficiencies were discussed, and he did not dispute the above findings.

Based on record review, policy review and interview, the facility failed to develop Master Treatment Plans (MTP) for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) that included individualized treatment interventions with a specific purpose and focus. The interventions on the MTPs were lists of generic discipline tasks/functions and were identical for all 8 patients despite their different diagnoses and presenting problems. Failure to clearly describe specific treatment modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs and may delay the patients' recovery.

Findings:

A. Record Review

1. Nursing Interventions

Patients A1 (MTP dated 7/24/19), A2 (MTP dated 8/21/19), A3 (MTP dated 8/9/19), A4 (MTP dated 8/22/19), A5 (MTP dated 7/30/19), A6 (MTP dated 8/13/19), A7 (MTP dated 8/19/19) and A8 (MTP dated 8/16/19) had the following identical nursing interventions:

"Provide medication education on prescribed medications, dosage, administration time, expected positive outcomes of medication adherence, possible side effects and when to notify health care provider." "Q [every] 15 min [minute] observation for unpredictable behavior." "Assess mood."

"Encourage group attendance and participation to increase acceptance and insight into illness, gain coping skills to deal with stressful/routine life situations. Give praise for all attempts to attend groups."

These interventions were generic nursing tasks and not individualized for each patient.

2. Social Work Interventions

Patients A1, A2, A3, A4, A5, A6, A7 and A8 had the following identical social work interventions:
"Assess patient's mood and behavior and its impact on patient's ability to adhere to treatment plan while on the unit and upon return to the community."

"Provide education regarding disturbing symptoms which could lead to re-hospitalization."
"Encourage and educate regarding adherence with post discharge instructions."
"Complete psychosocial assessment."
"Contact family/significant other."
"Maintain contact with community agencies.'
"Individual sessions 2x [times] per week to explore feelings and behaviors related to patient's diagnosis, symptoms, behaviors and support system in the community."
"To educate patient to recognize the consequences of non-adherence with treatment plan."
"To provide information from resources in the community which are available to patients to assist in finalizing a discharge plan."
"To promote interaction with group members in a safe supportive environment; to help peers express feelings/problems and receive support and encouragement from others."
These interventions were routine discipline tasks and were not individualized for each patient.

3. Activity/Occupational Therapy Interventions
Patients A1, A2, A3, A4, A5, A6, A7 and A8 had the following identical Activity/Occupational Therapy group interventions:
"Beauty care/Grooming"
"Stress Management"
"Leisure Education"
"Exercise/Physical Activity"
"Music/Music Therapy"
"Art/Art Therapy"
"Relaxation"
"Social Skills"
"Task skills group to include but not limited to initiation, attention, sequencing, organization, orientation, following directions, frustration tolerance, decision making skills."
"Life Skills Group including but not limited to anger management, self-awareness, self-esteem, coping skills, time management, relapse prevention, stress management, communication skills, self-care."
These interventions were routine discipline tasks and were not individualized for each patient. Furthermore, several of these patients did not attend groups.

B. Policy Review

The facility policy "Interdisciplinary Master Treatment Plan" (last revised on 5/9/18) stated, "Cornerstone Behavioral Health Hospital of Union County will develop a written individualized comprehensive interdisciplinary master treatment plan for each patient based on an assessment of the individual's strengths and weaknesses."
The facility did not adhere to this policy.

C. Interviews

1. On 9/4/19 at 1:40 p.m., the Director of Nursing stated, "I can see that the interventions are not specific to the patient."

2. On 9/4/19 at 2:45 p.m., the Director of Social Work stated, "The interventions could be more individualized."

3. On 9/4/19 at 3:00 p.m., the Director of Activity Therapies concurred that the interventions were not individualized.

Based on observation, record review, policy review and interviews, the facility failed to document active treatment measures or purposeful, alternative interventions for three (3) of eight (8) active sample patients (A1, A3 and A5) who were unable or unwilling to attend groups. This deficiency resulted in patients not receiving comprehensive, individualized therapies, potentially delaying their recovery and prolonging their hospitalization.

Findings:

A. Observation:

1. Patient A1 was admitted on 7/18/19 with a diagnosis of "Bipolar D/O Manic with Psychotic F (Features)". On 9/3/19 at 2:15 p.m., the patient was observed to be in the bed while "OT Group" was being conducted on the unit. Upon interview the patient informed the surveyor that she/he attends groups sometimes. Upon inquiry the unit RN I, stated "We encourage them to attend. We cannot force them to attend groups."

B. Record Review

The facility form "Activities Therapy/Occupational Progress Notes" revealed that Patient A1 attended 8 of 17 offered Activity Therapy groups from 8/22/19-8/28/19 and 1 of 5 Occupational Therapy groups from 8/21/19-8/28/19.

In the "Activity Therapy (AT) Progress Notes", the staff noted on 8/28/19 "Some participation, more of an observer." The Occupational Therapy (OT) notes for the same duration "Patient spending longer periods in bed." There was no documentation of alternative therapies being offered.

The "Nursing Group Participation Form" dated 8/26/19 through 9/1/19 revealed no documentations regarding alternative therapies offered to the patient for the groups this patient did not attend.

The Master Treatment Plan for Patient A1 dated 7/24/19 and last reviewed by the treatment team on 9/4/19 did not include any modifications in the goals or interventions to reflect the patient's unwillingness to attend groups or alternative therapies. The short-term goal (STG) number 4 dated 7/24/19 stated, "Patient will attend all groups for 30-45 minutes daily with relevant participation."

A. Observation

2. Patient A3 was admitted on 8/6/19 with a diagnosis of Schizophrenia. On 9/3/19 at 11:20 a.m., the patient was observed to be in the bed while an AT group was being conducted on the unit. Upon interview, the patient's thought process was found to be disorganized. S/He was unable to stay on topic and was preoccupied about getting discharged and getting a "Laptop."

B. Record Review

The facility form "Activities Therapy/Occupational Progress Notes" revealed that Patient A3 attended 6 of 16 offered Activity Therapy groups from 8/21/19-8/27/19 and 3 of 5 Occupational Therapy groups from 8/21/19-8/28/19. The AT Progress note for the same period noted patient as "Needs redirection to stay on topic," "Responding to internal stimuli," "Patient can be difficult to redirect and when this occurs, asked to leave the group." The OT notes indicate "Non relevant participation" "Responding to internal stimuli."

In the "Interdisciplinary Progress Notes" the social worker (SW) noted on 8/30/19 at 9:30 a.m. that the patient A3 "remains internally preoccupied, observed making bizarre gestures and talking to self. Pt. continues to be sexually preoccupied." This patient exhibited altered thought process and was unable to participate in group treatment modality, yet there was no documentation of alternative therapies being offered.

The patient's Master Treatment Plan dated 8/9/19 was last reviewed on 8/30/19 by the treatment team, which noted "Talking to [him/her] self, making bizarre gestures, attended some groups, unable to care for self." The treatment team did not alter the goals or interventions, including the STG #4, "Patient will attend all groups for 45 minutes daily with relevant participation," to reflect the patient's inability to attend groups or the inclusion of alternative individual therapies.

A. Observation

3. Patient A5 was admitted on 7/30/19 with a diagnosis of schizophrenia, paranoid type. On 9/3/19 at 11:00 a.m., the patient was observed to be in the bed and refused to go to group.

On 9/4/19 at 9:45 a.m., Patient A5's current Master Treatment Plan was reviewed in the Treatment Team. The treatment team did not alter the patient's STG #5, "Patient will attend 2-3 groups for 20 minutes daily with relevant participation," to reflect the patient's inability/unwillingness to attend groups or the inclusion of alternative individual therapies. The patient told the team, "No, I am not going to groups."

B. Record Review

The facility form "Activities Therapy/Occupational Progress Notes" revealed that Patient A5 attended 2 of 23 offered Activity Therapy groups from 8/20/19-8/26/19 and 0 of 5 Occupational Therapy groups from 8/20/19-8/26/19.
In the "Interdisciplinary Progress Notes" the social worker (SW) noted on 8/22/19 at 11:00 a.m. and on 8/30/19 at 8:40 a.m. that Patient A5 was "unable to tolerate groups." The social work intervention on the treatment plan stated, "Provide alternative activity to those patients who decline or are not comfortable with group interaction." However, on 8/15/19 at 2:00 p.m., the social worker (SW) noted that "SW did not meet [with] patient this week as patient's behavior is unpredictable. Patient did not attend SW groups as [patient] is unable to tolerate groups." There was no documentation of alternative therapies being offered.

The "Nursing Progress Notes" dated 8/28/19 through 9/3/19 revealed no alternative therapies offered to the patient. The "Group Participation Form" noted that Patient A5 was "in bed" during group times from 8/26/19 to 9/3/19.
The Master Treatment Plan for Patient 5 dated 7/30/19 and reviewed on 9/4/19 did not include any modifications in the goals or interventions to reflect the patient's unwillingness to attend groups or alternative therapies. The short-term goal (STG) number 5 dated 7/30/19 stated, "Patient will attend 2-3 groups for 20 minutes daily with relevant participation."

C. Policy Review

1.The facility policy "Group Participation Documentation" (last reviewed on 5/10/17) stated, "The assigned staff from Nursing, Social Work, Dietary, Activities Therapy, and Occupational Therapy will indicate the presence or absence of the patient, patient participation and alternatives offered to those patients who decline group."

2. The facility policy "Interdisciplinary Master Treatment Plan" (last reviewed on 5/9/18) stated, "The patient's treatment plan will involve the clinically appropriate treatment modalities. The treatment plan will contain specific goals for the patient. These goals will be reviewed and revised at the treatment team meetings by each discipline of the treatment team."

D. Interviews

1. On 9/3/19 at 11:00 a.m., Patient 5 told the surveyor, "No, I don't go to groups. People be [sic] talking about me there."

2. On 9/4/19 at 1:30 p.m., the Director of Nursing stated, "No, we do not document alternative interventions for patients who do not attend groups."

3. On 9/4/19 at 2:30 p.m., the Director of Social Work stated, "We definitely need to work on providing alternatives."

4. On 9/4/19 at 3:00 p.m., the hospital CEO confirmed that alternative therapies were not being provided to patients who were unwilling/unable to attend groups.

Based on record review and staff interview the Medical Director failed to ensure that;

I. The History and Physical examinations are comprehensive and include neurological examinations. (refer to B109).

II. The Psychiatric Assessments included an assessment and documentation of a patient's assets/personal attributes in a descriptive manner. (refer to B117)

III. The interdisciplinary MTPs were a) developed collaboratively and reflected and included the treatment team's agreed upon treatment goals and interventions, b) Treatment interventions were individualized to patient's clinical reality and functional capacity. (refer to B121 and B122)

IV. Active treatments, including alternative treatments, were provided to patients (patient A1,A3 and A5) who were unwilling or unable to attend routine unit activities and that the MTPs were revised to address patient's needs. (refer to B125)

These deficiencies result in a failure to guide treatment team members in providing patient-focused individualized treatments and potentially negatively affect patients' treatment and discharge.

Based on document review and interview, the facility failed to have a Director of Nursing with a Master's Degree, psychiatric nursing experience and /or documented evidence of consultation from a Registered Nurse with a Master's Degree in Psychiatric/Mental Health Nursing.

Findings:

A. Document Review

A review of the Director of Nursing's employment record revealed a Bachelor's of Science Degree in Nursing, graduating in 1979. The Director had approximately 2.5 years of experience in a psychiatric setting (since January 2017). Other prior experience was in medical settings or long-term convalescent care. There was no documentation of ongoing consultation with a Registered Nurse with a Master's in Psychiatric/Mental Health.

B. Interview

On 9/4/19 at 1:30 p.m., the Director of Nursing stated, "No, I do not have a Master's Degree and I do not have consultation with a Master's prepared Registered Nurse. I have only worked in psychiatry since January 2017."

The CEO confirmed on 9/4/19 at 3:00 p.m. that the Director of Nursing did not receive consultation with a Master's prepared Registered Nurse.

Based on record review, policy review and interview, the Director of Nursing failed to:

I. Develop individualized nursing interventions for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). This deficiency hampered staff's ability to provide treatment based on individual patient needs, potentially delaying recovery. (Refer to B122)

II. Provide alternative therapies for 3 of 8 sample patients (A1, A3 and A5) who were unwilling/unable to attend groups. This deficiency resulted in patients not receiving comprehensive, individualized therapies, thereby potentially delaying their recovery and possibly prolonging their hospitalization. (Refer to B125)

Based on record review, policy review and interview, the Activities Therapy Director failed to:

I. Develop individualized activity/occupational therapy interventions for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). This deficiency hampered staff's ability to provide treatment based on the individual patient needs and potentially delaying recovery. (Refer to B122)

II. Provide alternative therapies for three (3) of eight (8) sample patients (A1, A3 and A5) who were unwilling/unable to attend groups. This deficiency resulted in patients not receiving comprehensive, individualized therapies thereby potentially delaying their recovery and possibly prolonging their hospitalization. (Refer to B125)