HospitalInspections.org

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Based on record review and interview, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure:

1) Suicide safety precautions were followed for 1 Patient (#19), out of 1 patient reviewed for a suicide gesture and attempt;

2) Every-15 (Q15) minute observation check sheets (monitoring sheets that accompanied staff working with patients; staff were to physically locate and identify the patient's behavior, location, and position every 15 minutes of the day, 24 hours a day) were completed on the Arctic Recovery detox (detoxification - a structured approach to safely remove toxins or harmful substances from the body) unit for one full nightshift on 7/29/24, from 11:30 PM to 7/30/24 at 7:00 AM, for 4 Patients (#'s 8, 11, 15, and 18) actively on withdrawal protocol, out of 4 patients reviewed for that unit's total census.

3) Q15 minute observations were physically completed by staff, working with patients on the Arctic Recovery rehabilitation unit, accurately and timely; and

4) Q15 minute observation check sheets were completed accurately and timely for 13 Patients (#'s 2, 3, 4, 5, 6, 8, 9, 13, 16, 18, 19, 20, and 23), out of 26 patients reviewed for Q15 observation documentation.

These failed practices placed: 1) Patient #19 at risk for injury, up to and including death; 2) all patients of the Arctic Recovery detox unit on 7/29-30/24 (based on a census of 4) at risk for withdrawal adverse events, delay in care, and injury, up to and including death; and 3) all patients of the Arctic Recovery programs (based on a census of 14) at risk for subquality of care and safety risks due to decreased monitoring.

Findings:

1) Suicide Precautions for Safety

Patient #19

Record review on 8/8-19/24 revealed Patient #19 was admitted to the facility on 6/24/24 with diagnoses that included opioid dependence and other stimulant dependence.

Further review revealed that Patient #19's admission intake assessment, dated 6/24/24, revealed Patient #19 reported having fleeting suicidal ideation (thoughts of suicide) in the past month prior to admission. The intake assessment documented that Patient #19 reported that he/she had not work out, or started to work out, the details of how he/she would kill himself/herself and didn't think he/she would act upon these thoughts, however, did report a past serious attempt which required Cardiopulmonary Resuscitation (CPR) intervention. Patient #19's overall level of suicide risk status was "higher than patients who are safely treated on the inpatient unit."

Patient #19's High Risk Notification Alert, dated 6/24/24, revealed patient was placed on precautions for safety that included suicide and self-injury behavior.

A review of Patient #19's Q15 minute observation check sheets, dated 6/24/24 through 7/21/24, revealed Patient #19 remained on suicide and self-harm precautions throughout his/her admission.

7/5/24 Incident:

During an interview on 8/9/24 at 12:10 PM, Clinical Manager (CM) #1 stated that on Tuesday, 7/9/24, Patient #19 had reported he/she had attempted to "hang" himself/herself last Saturday (7/6/24) and was upset that no one had come to speak to him/her about this attempt yet. From this information, CM #1 started to investigate Patient #19's report, as it was not known this occurred, and informed leadership as well.

During an interview on 8/9/24 at 2:04 PM, the Risk Manager stated that CM #1 alerted leadership about Patient #19's report of his/her attempt to hang himself/herself on 7/6/24. CM #1 submitted an Incident Report (IR) into the facility's MIDAS system (their electronic reporting system for incidents) on 7/10/24, identifying the date of incident as 7/6/24, and the Risk Manager began an investigation. The Risk Manager stated a camera review and record review for 7/6/24 was completed with no indications of suicidal behavior or documentation of the incident was identified. However, the patient's doctor and clinical therapist were informed, and on 7/9/24, Patient #19 was placed on one-on-one (one staff assigned to one patient) observation for safety.

The Risk Manager did not review other dates to see if this incident might have occurred at a different time, nor if any other incidents or behaviors occurred regarding Patient #19.

During an interview on 8/13/24 at 12:56 PM, Licensed Nurse (LN) #11 stated that on 7/6/24 around 7:45 PM timeframe, he/she was asked to talk to Patient #19, who was tearful and not wanting to take his/her medication. LN #11 stated that when he/she walked down the unit's hall into Patient #19's bedroom, he/she stated he/she observed Patient #19 standing in the bathroom door frame holding onto the legs of a pair of legging-like pants that the patient had draped over the top of the bathroom door.

When asked how he/she interpreted Patient #19's behavior, LN #11 stated it was a suicidal gesture, as in the patient was testing to see if the pants could be used as a ligature. LN #11 further stated he/she intervened by asking Patient #19 to come into the dayroom to talk. LN #11 stated he/she talked with Patient #19 for about 30 to 45 minutes, had the second nurse (LN #5) secure the patient's bedroom, and offered Patient #19 medication for anxiety, which he/she had accepted. LN #11 stated he/she also requested Clinical Therapist (CT) #4 talk with Patient #19 to further help to calm him/her and assess for safety. LN #11 stated that after talking with Patient #19, CT #4 told him/her that Patient #19 wasn't suicidal and that a note would be written about the CT's interaction.

When asked what kind of documentation and notifications LN #11 made about the incident, LN #11 stated because there was not enough space on the nursing note to write out a total account of the incident, and he/she wrote a very brief synopsis and had assumed that CT #4's note would cover the rest of the incident. LN #11 stated he/she had not contacted the Patient's therapist or doctor about the incident. LN #11 had not completed an incident report, although admitted it should have been completed.

Review of Patient #19's medical record, on 8/13/24 at 1:00 PM, revealed no documentation from CT #4 of any encounters with Patient #19.

During the course of this complaint survey, the Assistant Chief Nursing Officer (ACNO) completed a more thorough review of the facility's staffing schedule, camera review, and medical record review, and on 8/13/24 determined that Patient #19's suicidal gesture actually occurred on Friday 7/5/24.

Review of Patient #19's nurse's note, dated 7/5/24 and completed by LN #11 for the night shift (7:00 PM through 7:00 AM), revealed written documentation dated 7/6/24 at 6:30 AM about the suicide gesture on evening of 7/5/24: "Behavior/Events . . . Thought Content: Goal oriented, SI [suicidal ideation] . . . RN [registered nurse] to Document to Treatment Plan Progress (Note observations, interventions, and Progress Towards Treatment Plan Goals): . . . At approx. [approximately] [7:35 PM] Pt [patient] was discovered [with] a makeshift "noose" draped over bathroom door. This nurse spoke [with] patient [administered] prn [as needed] Ativan [an antianxiety medication], advised Pt to speak [with] therapist. Pt denied SI/HI [suicidal ideation/homicidal ideation] . . . Pt met [with] therapist and processed [behaviors]. Patient denies having further thoughts of SI/HI at this time . . ."

Further review of the nurse's daily note, dated 7/5/24, revealed an AMSR (assessing and managing suicide risk) Daily Screening, that was completed for day shift (7:00 AM to 7:00 PM) and night shift (7:00 PM to 7:00 AM). Further review revealed for the night shift, LN #11 documented "No" to the question: "1. Thoughts: Since you were last asked, have you actually had thoughts about killing yourself? (if yes, ask 2-5, if no, go to #5)" and also answered "No" to the question: "5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end you life while hospitalized? If yes, what did you do?"

LN #11 did not answer the following questions: "2. Suicidal Thoughts with Method: Have you been thinking about how you might do this?", "3. Suicidal Intent (without Specific Plan): Have you had these thoughts and had some intention of acting on them?"; and "4. Suicide Intent with Specific Plan: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?" At the bottom of this screening was the following instructions: "If on Suicide Precautions perform AMSR ASSESSMENT. IF AMSR SCREENS POSITVE: Place on Suicide Precautions, contact physician, perform AMSR assessment."

A review of the facility's recorded video, dated 7/5/24 from 7:00 PM to 8:46 PM, revealed that LN #11 entered Patient #19's bedroom at 7:15 PM. At 7:19 PM, both LN #11 and Patient #19 exited the bedroom and went into the common area of the unit. LN #5 was observed to close Patient #19's bedroom door at 7:37 PM, however did not remove any items from the room. From 7:44 PM to 7:54 PM both nurses interacted with Patient #19 in the common area. At 7:57 PM, CT #4 was seen talking with the nurses in the nurse's station while Patient #19 remained in the common area. At 8:03 PM, CT #4 and Patient #19 entered an office together, and at 8:45 PM they exited. CT #4 was seen talking with the nurses in the nurse's station at 8:46 PM.

During an interview on 8/14/24 at 11:05 AM, the Risk Manager stated the camera review never showed staff removing items from Patient #19's bedroom. When informed it was a pair of legging-like pants that Patient #19 had used to hang over the bathroom door, the Risk Manager stated the pants should have been removed from Patient #19's bedroom for safety.

During an interview on 8/14/24 at 11:26 AM, CT #4 stated that when LNs #5 and #11 asked him/her to talk with Patient #19, they never indicated that Patient #19 had made a suicide gesture of hang pants over the bathroom door. CT #4 was asked to talk to Patient #19 because he/she was upset and was trying to leave Against Medical Advice. When asked if CT #4 had documented the encounter with Patient #19, he/she stated he/she had not because "[he/she] wasn't my patient." CT #4 stated he/she and Patient #19 processed what was currently bothering him/her and used deep breathing and light therapy to help de-escalate. Patient #19, once calm, decided to remain at the facility and continue treatment.

Patient #19 remained on one-on-one staffing precautions until 7/15/24, then returned to Q15 minute observations. Patient remained on suicide and self-harm precautions.

7/21/24 Incident

Review of Patient #19's nurse's note, dated 7/21/24 at 8:59 PM, revealed: ". . . Pt [patient] is pleasant and appropriate [with] interactions. Pt [Patient] denied SI/SH [suicidal ideation/self-harm] numerous times throughout the day. When this RN [registered nurse] went to admin [administer] nic [nicotine] lozenge at [2:30 PM] pt didn't respond to name as [he/she] usually does. When this RN went into pts room a tied sheet was observed in the corner of the door . . . This RN went to open door . . . pt fell to floor and was unconscious but did still have a pulse. Sternum rub performed [rubbing knuckles to a patient sternum to illicit a pain response] and pt [patient] gasped for air. [Physician #2] notified at [2:33 PM] pt sent to PAMC [Providence Alaska Medical Center] ED [emergency department] for further eval [evaluation]." At 9:45 PM the following was documented: "Pt [Patient] discharged following notification that pt [patient] was admitted to Prov [Providence] placed on psych [psychiatric] hold. Appropriate parties notified . . ."

During an interview on 8/9/24 at 3:05 PM, the Risk Manager stated Patient #19 used three pillowcases tied together with a pair of shorts with a drawstring to make a noose. The drawstring was used around the patient's neck.

During an interview on 8/9/24 at 3:38 PM, the Risk Manager stated Patient #19's 7/21/24 suicide attempt never should have happened as unit staff had not followed the facility's safety precautions restrictions outlined for safety.

Review of the facility's "Safety Precautions Standard Work" standardization of implementation of precautions, dated 1/16/23, revealed: ". . . Precautions are intended for specific use to ensure patient safety . . . Precautions are to be documented as a part of the treatment team plan. Restrictions should be implemented at the least restrictive level to current functioning:

- Safety considerations for all patients . . . Monitoring . . . Presence with patients to be maintained at all times (must be able to see/hear patients). Patient should never be left unattended . . . Patient room access: Doors to all rooms must remain closed during programming hours . . . Contraband/High Risk items: Please follow the contraband policy to ensure high risk items are not accessible to patients. Contraband searches on unit and in rooms to occur daily . . .

- Suicide Precautions: No clothing in patient room and no access to clothing . . . Monitored during dressing, bathing, and toileting with staff maintaining auditory contact. Patient never to be left alone behind a closed door . . . daily room and person contraband searches . . ."

Review of facility video recordings, dated 7/5/24, 7/6/24, and 7/21/24, revealed all unit bedroom doors were open during programming hours, Patient #19 was allowed to close his/her bedroom door at times for extended periods of time without staff present, and clothing was not restricted as Patient #19 was seen entering his/her bedroom, and then exiting in different clothes on two occasions on different days.

During an interview on 8/12/24 at 2:19 PM, while reviewing video recordings with surveyors, for the dates of 7/5/24 and 7/6/24, the Risk Manager stated bedroom doors were not allowed to be left open during programming hours as they were seen on videos.

Review of the facility's policy "Contraband Items/Suspected Drugs," effective 5/2024, revealed: ". . . contraband refers to property that is illegal and/or prohibited to possess in a psychiatric facility due to probability for the item to be used in a potentially harmful way. The item is prohibited due to the ability of the patient/resident to harm themselves or others either by using the item correctly or incorrectly . . . Staff will ensure that all items listed as contraband will be removed from the patient/resident to prevent self-harm or harm to others . . . The following items are considered contraband and will be taken upon admission to the hospital . . . and locked in a separate storage area . . . Drawstrings in clothing . . ."

Review of the facility's policy "Special Precautions and Levels of Monitoring, Motion Sensors," effective 5/2024, revealed: ". . . Suicide Precautions . . . The attending physician . . . may order suicide precautions for patient/residents who as assessed to be suicidal and, without heightened supervision, are at risk for self-harm up to and including death . . . When suicide precautions are ordered, the physician in collaboration with the treatment team will identify and order interventions to keep the patient safety . . . The RN [registered nurse] shall complete a suicide risk assessment each shift. Any change of the assessment indicating an enhanced risk of harm will be conveyed to the physician within 1 hour of the assessment . . . All patient/resident specific interventions will be review at each shift change by nursing and MHS staff . . ."

2) 7/29/24 Nightshift Q15 Observation Completion

The facility's Arctic Recovery program consisted of two units: the detox unit, where newly admitted patients went through detox protocols for close monitoring during withdrawal; and the rehabilitation unit, where patients move to after detox is completed and the participate in active programming.

During an interview on 8/8/24 at 12:29 PM, the Assistant Chief Nursing Officer (ACNO) stated that the facility had a goal of staffing each unit with at least one LN and one MHS. More staff would be added based on census and acuity of each unit.

During an interview on 8/11/24 at 12:40 AM, Mental Health Specialist (MHS) #61 stated that on the nightshift of 7/30/24, which started on 7/29/24 at 11:30 PM and stopped on 7/30/24 at 7:00 AM, the schedule reflected that the Arctic Recovery programs two units only had two LNs (#'s 9 and 46) and one MHS, himself/herself, and knew coming to work that day the units were missing one MHS. Due to census numbers, MHS #61 was assigned to the rehabilitation unit along with LN #46, and since there were only four patients on the detox unit, LN #9 was assigned to that side alone.

MHS #61 further stated that LN #9 was angry there was no MHS for the detox unit and stated it wasn't his/her responsibility to complete Q15 observation sheets and rounding. MHS #61 stated he/she stayed on the rehabilitation unit and completed his/her assigned duties all night. It wasn't until 7:00 AM on 7/30/24 that it was discovered LN #9 never completed any of the Q15 minute observations for the entire nightshift.

During an interview on 8/12/24 at 2:06 PM, the Risk Manager stated that through camera review it was confirmed that LN #9 hadn't completed any Q15 observation rounds on the nightshift on 7/29-30/24.

Review of Patient #'s 8, 11, 15, and 18's Q15 observation check sheets, from 7/29/24 at 11:30 PM to 7/30/24 at 7:00 AM, revealed no documentation every 15 minutes per policy. Further review revealed the following documentation over the 15-minute slots: "7/31/24: Late entry for 7/30/24. The Q15 documentation did not support rounding from [11:00 PM - 7:00 AM]. This was followed up on by nursing leadership."

Review of the facility's policy "Detoxification Services," effective 5/2024, revealed: ". . . The purpose of this policy is to establish treatment provision of services guidelines for patients/residents who are in need of detoxification services in a manner that . . . May relieve the patient's/resident's discomfort . . . Prevent the development of more serious symptoms, and . . . Forestall cumulative effects that might worsen future withdrawals . . . [The facilities] are equipped to provide detoxification services that meet the unique recovery needs of the medically compromised patient . . . The intensity of withdrawal cannot always be predicted accurately and requires close observation . . . A precaution flow sheet will be initiated at the time of admission and the patient will be monitored at fifteen (15) minute intervals. Note: Patients who are at a higher risk for over sedation and respiratory depression include: Patient with new orders for opioids-first 24 hours, Patients with shallow respirations upon respiratory assessment as indicated by monitoring the risk and fall of the patient's chest to determine the rate, depth, and regularity of respirations, [and] patient with periods of apnea . . ."

3) Conducting Q15 minute Observation Reviews

Q15 minute Observation Protocol

Review of the facility's policy "Special Precautions and Levels of Monitoring, Motion Sensors," effective 5/2024, revealed: ". . . The standard monitoring procedure in all [facility name] facilities is 15 minutes visual monitoring unless otherwise ordered by the physician. During 15 minute monitoring, staff are to directly observe the patient/resident every 15 minutes while remaining close enough to hear the patient/resident and respond to needs and events at all times . . . Documentation: Monitoring staff will maintain an observation record and document every 15 minutes the patient's/resident's location and observed behavior. The RN [registered nurse] will provide oversight of the observation rounds and will document oversight at least 3 times in a 12-hour period (a minimum of 6 times in 24/hour period) . . ."

The facility utilized a patient observation sheet called a "Patient Observation Record [and] Milieu Group" sheet. This sheet had blocked times every 15 minutes and staff would document at each 15-minute interval the patient's location, behavior, and position. Nurses would then check these observation sheets, called "nursing oversight" on the sheet, three times per their 12-hour shift to ensure they were completed accurately and timely, by signing and dating the sheets at each oversight.

During an interview on 8/13/24 at 8:30 AM, the Program Educator stated MHS and LN staff received training on Q15-minute observation policy, and documentation to be completed during patient observations, at their new hire orientation. The Program Educator further stated staff signed a Q15-minute observation attestation which stated they understood the education and would follow the protocol standards.

Camera Reviews

Review of facility recorded video on the Arctic Recovery rehabilitation unit, on 7/6/24 from 9:30 AM to 10:49 AM, revealed no Q15 minute rounding was physically conducted from 9:42 AM to 10:47 AM (1 hours and 5 minutes). During this timeframe there were patients in their rooms and out of sight from staff.

Review of Q15 minute observation documentation revealed observations were documented as being completed every 15 minutes during these missed rounding periods.

Review of facility recorded video on the Arctic Recovery rehabilitation unit, on 7/6/24 from 7:38 PM to 11:23 PM, revealed no Q15 minute rounding was physically conducted from 7:42 PM to 11:07 PM (3 hours and 25 minutes). During this timeframe there were patients in their rooms and out of sight from staff.

Review of Q15 minute observation documentation revealed observations were documented as being completed every 15 minutes during these missed rounding periods.

4) Q15 Minute Observation Check Sheet Documentation Review

Review of patient Q15 minute observation sheets, on 8/8-19/24, revealed:

Patient #2

Record revealed Patient #2 was admitted to the facility on 6/13/24 with a diagnosis of alcohol dependence and cannabis abuse.

Review of Patient #2's Q15 observation sheets revealed the following deficiencies:

- 7/5/24: The Q15 observation sheet was missing one nightshift (7:00 PM - 7:00 AM) Licensed Nurse (LN) oversight signature. Further review of the sheet revealed there was no documentation of the patient's location, behavior, or position at 11:15 AM and 1:45 PM.

- 7/6/24: The Q15 observation sheet was missing one nightshift and two dayshift (7:00 AM - 7:00 PM) LN oversight signatures.

- 7/19/24: The Q15 observation sheet was missing all three of the nightshift LN oversight signatures.

- 7/20/24: The Q15 observation sheet was missing all six of the LN oversight signatures.

- 7/22/24: The Q15 observation sheet was missing one nightshift LN oversight signature.

- 8/7/24: The Q15 observation sheet was missing two nightshift LN oversight signatures.

- 8/8/24: The Q15 observation sheet was missing one nightshift LN oversight signature.

Patient #3

Record revealed Patient #3 was admitted to the facility on 7/9/24 with a diagnosis of opioid dependence and other stimulant dependence, uncomplicated.

Review of Patient #3's Q15 monitoring sheets revealed the following deficiencies:

- 8/7/24: The Q15 monitoring sheet was missing one nightshift and one dayshift LN oversight signatures.

- 8/8/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature.

Patient #4

Record revealed Patient #4 was admitted to the facility on 7/22/24 with a diagnosis of alcohol dependence.

Review of Patient #4's Q15 monitoring sheets revealed the following deficiencies:

- 7/22/24: The Q15 monitoring sheet was missing all three of the nightshift LN oversight signatures and two dayshift LN oversight signatures.

- 8/7/24: The Q15 monitoring sheet was missing two nightshift LN oversight signatures.

Patient #5

Record revealed Patient #5 was admitted to the facility on 7/18/24 with a diagnosis of alcohol dependence and other stimulant dependence, uncomplicated.

Review of Patient #5's Q15 monitoring sheets revealed the following deficiencies:

- 7/20/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature.

- 7/21/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature.

- 7/22/24: The Q15 monitoring sheet was missing all three of the dayshift LN oversight signatures.

- 8/7/24: The Q15 monitoring sheet was missing two nightshift LN oversight signatures.

- 8/8/24: The Q15 monitoring sheet was missing one nightshift LN oversight signatures.

Patient #6

Record revealed Patient #6 was admitted to the facility on 8/5/24 with a diagnosis of post-traumatic stress disorder (PTSD)

Review of Patient #6's Q15 monitoring sheet, dated 8/6/24, revealed it was missing two nightshift LN oversight signatures.

Patient #8

Record revealed Patient #8 was admitted to the facility on 8/6/24 with a diagnosis of PTSD.

Review of Patient #8's Q15 monitoring sheet, dated 8/6/24, was missing two nightshift LN oversight signatures.

Patient #9

Record revealed Patient #9 was admitted to the facility on 7/22/24 with a diagnosis of PTSD.

Review of Patient #9's Q15 monitoring sheet, dated 8/6/24, was missing two nightshift LN oversight signatures.

Patient #13

Record revealed Patient #13 was admitted to the facility on 2/10/24 through 5/12/24 with a diagnosis of major depressive disorder, recurrent, severe, with psychosis.

Review of Patient #13's Q15 monitoring sheets revealed the following deficiencies:

- 2/10/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature.

- 2/18/24: The Q15 monitoring sheet was missing one nightshift and all three of the dayshift LN oversight signatures.

- 2/29/24: The Q15 monitoring sheet revealed there was no documentation of the patient's location, behavior, or position at 7:45 AM and 14:30 PM.

- 4/5/24: The Q15 monitoring sheet was missing two dayshift LN oversight signatures. Further review of the sheet revealed there was no documentation of the patient's location, behavior, or position at 4:30 PM.

- 4/6/24: The Q15 monitoring sheet was missing all three of the dayshift LN oversight signatures. Further review of the sheet revealed there was no documentation of the patient's location, behavior, or position at 8:15 PM and 8:30 PM.

Patient #16

Record revealed Patient #16 was admitted to the facility on 6/1/24 through 8/2/24 with a diagnosis of major depressive disorder, single episode, severe with psychotic features.

Review of Patient #16's Q15 monitoring sheets revealed the following deficiencies:

- 6/18/24: The Q15 monitoring sheet revealed there was no documentation of the patient's location, behavior, or position at 3:45 PM.

-7/10/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature.

Patient #18

Record revealed Patient #18 was admitted to the facility on 7/22/24 through 8/1/24 with a diagnosis of alcohol dependence.

Review of Patient #18's Q15 monitoring sheet, dated 7/22/24, was missing two nightshift and all three of the dayshift LN oversight signatures.

Further review of the 7/22/24 Q15 observation sheet revealed there was no documentation of the patient's location, behavior, or position at 7:15 PM, 7:30 PM, 7:45 PM, 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:00 PM, and 9:15 PM.

Patient #19

Record revealed Patient #19 was admitted to the facility on 6/24/24 through 7/21/24 with a diagnosis of opioid dependence and other stimulant dependence.

Review of Patient #19's Q15 monitoring sheets revealed the following deficiencies:

- 7/6/24: The Q15 monitoring sheet was missing one nightshift and two dayshift LN oversight signatures.

-7/21/24: The Q15 monitoring sheet was missing one nightshift LN oversight signatures.

Patient #20

Record revealed Patient #20 was admitted to the facility on 7/22/24 through 7/26/24 with a diagnosis of alcohol dependence and other stimulant dependence.

Review of Patient #20's Q15 monitoring sheet, dated 7/22/24, was missing all three of nightshift LN oversight signatures.

Patient #23

Record revealed Patient #23 was admitted to the facility on 7/22/24 through 7/24/24 with a diagnosis of alcohol dependence.

Review of Patient #23's Q15 monitoring sheet, dated 7/22/24, was missing all three of nightshift and two dayshift LN oversight signatures.

Review of the facility's policy "Patient Rights," effective 5/2023, revealed: ". . . It is the policy of the [facility] to protect the fundamental, human, civil, and constitutional rights of each patient/resident . . . The right to move about freely on the unit as their treatment plan and unit safety allow . . . The right to a clean and safe unit and hospital . . . [the facility] seeks to render care and treatment in a way that considers, respects, and protects the rights and personal dignity of each patient/resident . . . Care will be provided at the least restrictive level consistent with patient/resident safety and the treatment plan . . ."
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Based on record review and interview, the facility failed to meet the Condition of Participation of Quality Assessment and Performance Improvement Program (QAPI) in accordance with CFR 482.21. The facility failed to comply with Federal requirements to maintain an effective, ongoing, hospital-wide, data-driven QAPI program that focused on indicators related to improved health outcomes and the prevention and reduction of medical errors to include quality assessment and performance improvement.

Findings:

1. The facility's QAPI Program failed to identify opportunities for improvement and changes that would lead to improvement. Specifically, the QAPI Program failed to: 1) collect data on suicide behavior, gestures, and attempts to ascertain potential opportunities to mitigate occurrences; and 2) set priorities for its performance improvement activities that considered the suicide incidence, prevalence, and severity of the problem. (Refer to A-283).

2. The facility's QAPI Program failed to measure, analyze, and track adverse patient events that included: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits.

On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the QAPI program's failure to design and implement a program that measured, analyzed, and tracked adverse events.

The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM.

Implementation of the removal plan was verified on 8/16/24. The immediacy was removed on 8/16/24 at 9:58 AM.

Following the removal of the immediacy, noncompliance remained that was not immediate. (Refer to A-286).

3. The facility failed to ensure facility's Governing Body, medical staff, and administrative officials were responsible and accountable for ensuring that the hospital-wide QAPI Program efforts addressed priorities for improved quality of care and patient safety specific to: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits. (Refer to A-309).
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Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) Program failed to identify opportunities for improvement and changes that would lead to improvement. Specifically, the QAPI Program failed to: 1) collect data on suicide behavior, gestures, and attempts to ascertain potential opportunities to mitigate occurrences; and 2) set priorities for its performance improvement activities that considered the suicide incidence, prevalence, and severity of the problem. This failed practice limited the QAPI Program from reviewing potential deficient practices, that could have contributed to opportunities of suicidal behavior, gestures, and attempts, and placed all patient (based on a census of 63) at risk for injury, up to and including death, and/or substandard quality of care.

Findings:

Patient #19

Record review on 8/8-19/24 revealed Patient #19 was admitted to the facility on 6/24/24 with diagnoses that included opioid dependence and other stimulant dependence. Patient #19 was also assessed as being high risk for suicide and self-harm behavior and was placed on suicide and self-harm precautions.

Reviews of Patient #19's medical records and facility camera recordings, dated 7/5/24 and 7/21/24, revealed Patient #19 made a suicidal gesture on 7/5/24 witnessed by staff, by draping a pair of legging-like pants over the bedroom's bathroom door as a makeshift "noose", and then made a suicide attempt, by hanging on 7/21/24 to the point of losing consciousness and required medical intervention.

Facility's Investigation

7/5/24 Incident

Review of the facility's investigation, of the 7/5/24 incident, revealed the facility's inability to thoroughly investigation the incident and to correctly identify the actual date of when the incident occurred and because of this, subsequently did not identify potential deficient practices that could have contributed to the incident:

During an interview on 8/9/24 at 12:10 PM, Clinical Manager (CM) #1 stated that on Tuesday, 7/9/24, Patient #19 had reported he/she had attempted to "hang" himself/herself last Saturday (7/6/24) and was upset that no one had come to process this attempt yet. From this information, CM #1 started to investigate Patient #19's report, as it was not known this occurred, and informed leadership as well.

During an interview on 8/9/24 at 2:04 PM, the Risk Manager stated that CM #1 alerted leadership about Patient #19's report of his/her attempt to hang himself/herself on 7/6/24. CM #1 submitted an Incident Report (IR) into the facility's MIDAS system (their electronic reporting system for incidents) on 7/10/24, identifying the date of incident as 7/6/24, and the Risk Manager began an investigation. The Risk Manager stated a camera review and record review for 7/6/24 was completed with no indications of suicidal behavior or documentation of the incident was identified.

The Risk Manager did not review other dates to see if this incident might have occurred at a different time, nor if any other incidents or behaviors occurred regarding Patient #19.

During the course of this complaint survey, the Assistant Chief Nursing Officer (ACNO) completed a more thorough review of the facility's staffing schedule, camera review, and medical records review, and on 8/13/24 determined that Patient #19's suicidal behavior actually occurred on Friday 7/5/24.

During an interview on 8/13/24 at 9:51 AM, the Chief Nursing Officer (CNO) stated that Licensed Nurse (LN) #11, who was a travel nurse, was working the day Patient #19 made the 7/6/24 suicide gesture and failed to complete an Incident Report (IR), failed to document the incident in the nurse's note for that shift, and did not notify the Provider. (At the time of the CNO's investigation, the facility still had the 7/6/24 date identified as the date of incident)

During an interview on 8/13/24 at 11:00 AM, the CNO stated she had only learned of the incident 3 days later and completed a telephone interview with LN #11 to ascertain what exactly occurred, however did not document this interview. The CNO further stated that because LN #11 was a travel nurse, the facility didn't have the authority to discipline travel nurses and that the travel agency was contacted to do this. The CNO stated she verbally coached LN #11 on the appropriate processes for submitting an IR, however the absence of documentation for Patient #19's suicidal gesture was not addressed. The CNO stated this coaching was not documented.

During an interview on 8/13/24 at 11:45 AM, the Human Resources Director stated she was not informed of the need to contact any travel agency for disciplinary needs for LN #11.

During an interview on 8/14/24 at 9:37 AM, the Quality Director stated the facility acknowledged it could have done better documenting the 7/5/24 incident and the facility's investigation of the incident.

7/21/24 Incident

Review of the facility's investigation, of the 7/21/24 incident, revealed the facility failed to ensure unit staff followed facility standardization of implementation of safety precautions to mitigate the potential for Patient #19's suicide attempt, that were present during the 7/5/24 incident.

Review of the facility's "Safety Precautions Standard Work" standardization of implementation of precautions, dated 1/16/23, revealed: ". . . Precautions are intended for specific use to ensure patient safety . . . Precautions are to be documented as a part of the treatment team plan. Restrictions should be implemented at the least restrictive level to current functioning:

- Safety considerations for all patients . . . Monitoring . . . Presence with patients to be maintained at all times (must be able to see/hear patients). Patient should never be left unattended . . . Patient room access: Doors to all rooms must remain closed during programming hours . . . Contraband/High Risk items: Please follow the contraband policy to ensure high risk items are not accessible to patients. Contraband searches on unit and in rooms to occur daily . . .

- Suicide Precautions: No clothing in patient room and no access to clothing . . . Monitored during dressing, bathing, and toileting with staff maintaining auditory contact. Patient never to be left alone behind a closed door . . . daily room and person contraband searches . . ."

During an interview on 8/9/24 at 3:38 PM, the Risk Manager stated Patient #19's 7/21/24 suicide attempt never should have happened as unit staff had not followed the facility's safety precautions restrictions outlined for safety.

Review of facility video recordings, dated 7/5/24, 7/6/24, and 7/21/24, revealed all unit bedroom doors were open during programming hours, Patient #19 was allowed to close his/her bedroom door at times for extended periods of time without staff present, and clothing was not restricted as Patient #19 was seen entering his/her bedroom, and then exiting in different clothes on two occasions on different days.

During an interview on 8/12/24 at 2:19 PM, while reviewing video recordings with surveyors, the Risk Manager stated bedroom doors were not allowed to be left open during programming hours as they were seen on videos.

Facility Risk Management and Quality Assurance Oversignt

During an interview on 8/13/24 at 10:47 AM, the Risk Manager stated the Patient Safety Council meetings were completed once a month and the committee measured and monitored the following items:

- Restraints/Seclusions rates;
- Patient injuries in restraints/seclusions;
- Patient aggression with and without injuries;
- Elopements;
- Falls;
- Medication variances (like medication errors or adverse reactions); and
- Patient safety alert advisory topics (these are presented to staff for reminders to help assure safety. Example: keep keys and badges secure)

Review of facility Patient Safety Council meeting minutes, dated 1/2024 through 6/2024, revealed no measurements or monitoring for suicide behavior, gestures, or attempts.

During an interview on 8/13/24 at 12:09 PM, the Quality Director stated the facility's Performance Improvement (PI) committee (the facility's QAPI Program) only monitored performance tasks.

Review of the facility's "BH [Behavioral Health] Performance Indicator Database - Acute" list, undated, revealed the list included "Suicide Risk Assessment/Management" which measured: "Compliance with initial suicide risk assessment; overall suicide risk level documented and proper mitigation taken based on risk level; do precautions march risk level; discharge education provided based on risk."

Further review of the performance indicator list revealed no monitoring of suicide behavior, gesture, or attempts.

During an interview on 8/15/24 at 12:42 PM, the Risk Manager and Quality Director stated that suicidal behavior, gesture, and attempt data was not collected and assessed for performance improvement activities.

Review of the facility's "Quality Assurance [and] Performance Improvement (QAPI)" plan, dated 2024, revealed: ". . . The successful execution of the QAPI program is the result of the foundation of leadership commitment, education in performance improvement techniques, commitment of resources to execute improvement opportunities, information management systems for data display and comparisons and employee involvement in improving their own work processes . . . We believe important hospital processes and functions that perform well result in high quality patient care. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its systems and processes. The 2024 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes . . ."
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Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) Program failed to measure, analyze, and track adverse patient events that included: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits. This failed practice limited the QAPI Program from reviewing potential deficient practices, that could have contributed to: 1) opportunities of suicidal behavior, gestures, and attempts; and 2) the need for emergent higher level of care. This placed all patient (based on a census of 63) at risk for injury, up to and including death, and/or substandard quality of care.

On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the QAPI program's failure to design and implement a program that measured, analyzed, and tracked adverse events.

The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM.

Implementation of the removal plan was verified on 8/16/24. The immediacy was removed on 8/16/24 at 9:58 AM.

Following the removal of the immediacy, noncompliance remained that is not immediate.

Findings:

Suicide Behavior, Gestures, and Attempts

Patient #19

Record review on 8/8-19/24 revealed Patient #19 was admitted to the facility on 6/24/24 with diagnoses that included opioid dependence and other stimulant dependence. Patient #19 was also assessed as being high risk for suicide and self-harm behavior and was placed on suicide and self-harm precautions.

Reviews of Patient #19's medical records and facility camera recordings, dated 7/5/24 and 7/21/24, revealed Patient #19 made a suicidal gesture on 7/5/24 witnessed by staff, by draping a pair of legging-like pants over the bedroom's bathroom door as a makeshift "noose", and then made a suicide attempt, by hanging on 7/21/24 to the point of losing consciousness and required medical intervention.

Facility's Investigation

7/5/24 Incident

Review of the facility's investigation, of the 7/5/24 incident, revealed the facility's inability to thoroughly investigation the incident and to correctly identify the actual date of when the incident occurred and because of this, subsequently did not identify potential deficient practices that could have contributed to the incident:

During an interview on 8/9/24 at 12:10 PM, Clinical Manager (CM) #1 stated that on Tuesday, 7/9/24, Patient #19 had reported he/she had attempted to "hang" himself/herself last Saturday (7/6/24) and was upset that no one had come to process this attempt yet. From this information, CM #1 started to investigate Patient #19's report, as it was not known this occurred, and informed leadership as well.

During an interview on 8/9/24 at 2:04 PM, the Risk Manager stated that CM #1 alerted leadership about Patient #19's report of his/her attempt to hang himself/herself on 7/6/24. CM #1 submitted an Incident Report (IR) into the facility's MIDAS system (their electronic reporting system for incidents) on 7/10/24, identifying the date of incident as 7/6/24, and the Risk Manager began an investigation. The Risk Manager stated a camera review and record review for 7/6/24 was completed with no indications of suicidal behavior or documentation of the incident was identified.

The Risk Manager did not review other dates to see if this incident might have occurred at a different time, nor if any other incidents or behaviors occurred regarding Patient #19.

During the course of this complaint survey, the Assistant Chief Nursing Officer (ACNO) completed a more thorough review of the facility's staffing schedule, camera review, and medical records review, and on 8/13/24 determined that Patient #19's suicidal behavior actually occurred on Friday 7/5/24.

During an interview on 8/13/24 at 9:51 AM, the Chief Nursing Officer (CNO) stated that Licensed Nurse (LN) #11, who was a travel nurse, was working the day Patient #19 made the 7/6/24 suicide gesture and failed to complete an Incident Report (IR), failed to document the incident in the nurse's note for that shift, and did not notify the Provider. (At the time of the CNO's investigation, the facility still had the 7/6/24 date identified as the date of incident)

During an interview on 8/13/24 at 11:00 AM, the CNO stated she had only learned of the incident 3 days later and completed a telephone interview with LN #11 to ascertain what exactly occurred, however did not document this interview. The CNO further stated that because LN #11 was a travel nurse, the facility didn't have the authority to discipline travel nurses and that the travel agency was contacted to do this. The CNO stated she verbally coached LN #11 on the appropriate processes for submitting an IR, however the absence of documentation for Patient #19's suicidal gesture was not addressed. The CNO stated this coaching was not documented.

During an interview on 8/13/24 at 11:45 AM, the Human Resources Director stated she was not informed of the need to contact any travel agency for disciplinary needs for LN #11.

During an interview on 8/14/24 at 9:37 AM, the Quality Director stated the facility acknowledged it could have done better documenting the 7/5/24 incident and the facility's investigation of the incident.

7/21/24 Incident

Review of the facility's investigation, of the 7/21/24 incident, revealed the facility failed to ensure unit staff followed facility standardization of implementation of safety precautions to mitigate the potential for Patient #19's suicide attempt, that were present during the 7/5/24 incident.

Review of the facility's "Safety Precautions Standard Work" standardization of implementation of precautions, dated 1/16/23, revealed: ". . . Precautions are intended for specific use to ensure patient safety . . . Precautions are to be documented as a part of the treatment team plan. Restrictions should be implemented at the least restrictive level to current functioning:

- Safety considerations for all patients . . . Monitoring . . . Presence with patients to be maintained at all times (must be able to see/hear patients). Patient should never be left unattended . . . Patient room access: Doors to all rooms must remain closed during programming hours . . . Contraband/High Risk items: Please follow the contraband policy to ensure high risk items are not accessible to patients. Contraband searches on unit and in rooms to occur daily . . .

- Suicide Precautions: No clothing in patient room and no access to clothing . . . Monitored during dressing, bathing, and toileting with staff maintaining auditory contact. Patient never to be left alone behind a closed door . . . daily room and person contraband searches . . ."

During an interview on 8/9/24 at 3:38 PM, the Risk Manager stated Patient #19's 7/21/24 suicide attempt never should have happened as unit staff had not followed the facility's safety precautions restrictions outlined for safety.

Review of facility video recordings, dated 7/5/24, 7/6/24, and 7/21/24, revealed all unit bedroom doors were open during programming hours, Patient #19 was allowed to close his/her bedroom door at times for extended periods of time without staff present, and clothing was not restricted as Patient #19 was seen entering his/her bedroom, and then exiting in different clothes on two occasions on different days.

During an interview on 8/12/24 at 2:19 PM, while reviewing video recordings with surveyors, the Risk Manager stated bedroom doors were not allowed to be left open during programming hours as they were seen on videos.

Facility Risk Management and Quality Assurance Oversignt

During an interview on 8/13/24 at 10:47 AM, the Risk Manager stated the Patient Safety Council meetings were completed once a month and the committee measured and monitored the following items:

- Restraints/Seclusions rates;
- Patient injuries in restraints/seclusions;
- Patient aggression with and without injuries;
- Elopements;
- Falls;
- Medication variances (like medication errors or adverse reactions); and
- Patient safety alert advisory topics (these are presented to staff for reminders to help assure safety. Example: keep keys and badges secure)

Review of facility Patient Safety Council meeting minutes, dated 1/2024 through 6/2024, revealed no measurements or monitoring for suicide behavior, gestures, or attempts.

During an interview on 8/13/24 at 12:09 PM, the Quality Director stated the facility's Performance Improvement (PI) committee (the facility's QAPI Program) only monitored performance tasks.

Review of the facility's "BH [Behavioral Health] Performance Indicator Database - Acute" list, undated, revealed the list included "Suicide Risk Assessment/Management" which measured: "Compliance with initial suicide risk assessment; overall suicide risk level documented and proper mitigation taken based on risk level; do precautions march risk level; discharge education provided based on risk."

Further review of the performance indicator list revealed no monitoring of suicide behavior, gesture, or attempts.

ED Visits

Detoxification (Detox) Protocol

The facility had two inpatient programs for adults: 1) The Arctic Recovery Program which offered detox and rehabilitation for substance abuse to civilians; and 2) The Chris Kyle Patriot Hospital which offered trauma-focused care, detox and rehabilitation for military, veterans, their families, and first responders.

During the detox process, nurses monitored newly admitted patients through their withdrawal symptoms and provided scheduled and PRN (as needed) medications and treatments to help safely guide them through detoxing from alcohol and/or opioids (narcotic medications). Two assessment forms were used:

1. Alcohol Withdrawal - A Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) form; and
2. Opioid Withdrawal - A Clinical Opiate Withdrawal Scale (COWS) form.

The detox monitoring typically started upon admission and was completed every 4 hours, then graduated to every 6 hours and then every 8 hours, depending on how individual patients responded to detoxing. These assessments entailed obtaining vital signs and rating the patient's symptoms on severity scales. A total score would be ascertained at every assessment, and based on that total score medications would be administered and treatments would be implemented.

During an interview on 8/12/24 at 4:24 PM, LN #2 stated new nurses completed an in-class structured orientation, and after this would have 2 to 3 shadow days with a nurse to learn the role. After this, new nurses were assigned a shift and put into direct patient care. LN #2 stated that from his/her experience in working with newly hired nurses, they weren't prepared and didn't know where things were or how to appropriately monitor detox patients.

During an interview on 8/12/24 at 4:45 PM, LN #8 stated newly hired nurses didn't know their roles after they completed orientation and shadow days. Experiencing orientation when hired, LN #8 stated he/she had no detox training at orientation and hadn't known about withdrawal symptoms from alcohol or substances, how to perform CIWA (shortened version of CAIW-Ar) or COWS screenings, and what the scores meant.

7/31/24 Incident

During an interview on 8/12/24 at 5:31 PM, LN #7 stated he/she had picked up an extra shift on Arctic Recovery, which started at 11:00 PM. When he/she arrived, it was discovered that Patient #8 was newly admitted for alcohol dependence and was experiencing distressing withdrawal symptoms. When LN #7 talked with the nurses who were currently working, LNs #30 and #41, it was discovered the nurses had not provided withdrawal PRN medication interventions, since admission because they thought it was facility policy that they could not provide medications if the patient's blood alcohol level was still elevated and not within the legal limit (0.08 in Alaska), which was not the case. LN #7 stated he/she began to assess Patient #8. His/her blood alcohol level was 0.11 and he/she was shaking to the point that a wheelchair was required to transfer the patient to his/her bedroom. LN #7 initiated PRN medication interventions, of Ativan (an antianxiety medication) and attempted to get the patient's symptoms under control, however, could not. At around 5:00 AM, LN #7 called the provider on-call and received orders to have the patient transferred to the ED. The patient was subsequently admitted to the hospital. LN #7 further stated that an incident report was filed, and he/she reported to nursing leadership of the concern that these newer nurses were not administering detox protocols appropriately which may have contributed to Patient #8's decline and need for emergent higher level of care.

Review of Patient #8's medical record, dated 7/31/24 through 8/1/24, revealed the following information:

- Patient #8's blood alcohol level upon admission, on 7/31/24 at 10:15 AM, was 0.36 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled "Alcohol's Effects on Health", dated January 2023 reveal a level between 0.31 to 0.45 is considered life threating and may contribute to unconsciousness and significant risk of death due to suppression of vital life functions.)
- Patient #8 had a history of seizures, the last seizure occurred in 5/2023.
- During the admission process, Patient #8 had vomited and was sent over to the ED for medical clearance prior to being admitted. Patient was medically cleared and returned to the facility around 5:00 PM.
- At 5:00 PM, Patient #8's CIWA score was 9 (which indicated minimal to mild withdrawal), however was rated as having visible tremors, more than mildly anxious, and had beads of sweat obvious on his/her forehead. No medication intervention was documented as given.
- At 6:00 PM, his/her blood alcohol level was 0.27 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled "Alcohol's Effects on Health", dated January 2023 reveal a level between 0.15 to 0.30 is considered severe impairment and may contribute to confusion, vomiting, drowsiness, and unconsciousness.)
- At 8:00 PM, Patient #8's CIWA score was 10 (which still indicated minimal to mild withdrawal), however his/her symptoms were more increased: mildly nauseous, tremors were less, mildly anxious, beads of sweat were still visible on forehead, and had a mild headache or fullness in head. LN #30 documented "1.9 BRAK [blood alcohol level] scheduled" where medications were to be listed if given. Medications that were given was gabapentin (An anticonvulsant medication used for seizures, nerve pain, and restless legs) at 8:38 PM, Seroquel at 8:39 PM, and Tylenol at 8:40 PM.
- Once LN #7 was on shift, he/she took over Patient #8's care.
- At 12:00 AM, Patient #8's CIWA score was 9, with elevated anxiety and headache, and LN #7 administered Tylenol and Ativan by mouth.
- At 3:10 AM, Patient #9's CIAWA score remained 9, however Patient #8's anxiety increased. Ativan was again administered by mouth.
- At 4:30 AM, Patient #8's CIWA score was 18 (which indicated severe withdrawal), and Ativan was administered via injection. When this was not effective, LN #7 notified the provider and the decision was made to transport the patient to the ED. Patient #8 left, with a staff escort and EMS at 5:50 AM.

Patient #8 was without withdrawal PRN medication treatment for approximately 6 hours prior to LN #7 arriving for work.

During an interview on 8/13/24 at 11:00 AM, the ACNO stated LN #7 did contact her and the CNO about the 7/31/24 incident and verbalized concerns that LNs #30 and #41 didn't give CIWA score intervention. As they investigated this, nursing leadership realized there was a gap in the CIWA and COWS assessments and ordered medication interventions, where that there were no parameters set to alert nurses to provide certain interventions based on scores of the assessments. The ACNO stated that they were working with the facility's pharmacist to add score parameters for medications, however this was not completed and not being used by nurses currently.

During an interview at 8/15/24 at 10:02 AM, when asked what Risk had investigated regarding the 7/31/24 incident, the Risk Manager stated, "I don't investigate stuff like this" and stated she referred it to nursing leadership to review.

During an interview on 8/15/24 at 11:06 AM, the ACNO stated that the Incident Report was reviewed during safety huddle and nursing leadership followed up on the change of condition to only see if the patient returned to the facility or not. Usually, when a patient went to the ED, nurse leadership ascertained if they returned to the facility, and if they did, to ensure they were seen by medical personnel the next day. Patient #7 had not returned to the facility. When asked if the facility ever requests medical records for patients that were seen at the ED, the ACNO stated no and that they only received records that were returned with patients from the ED.

When asked what nursing leadership had done regarding the 7/31/24 incident and the nurse's misinterpretation of how to perform detox assessments and interventions, the ACNO stated because LN #7 stated he/she had educated LNs #30 and #41 that night, nursing leadership provided no education, guidance, or coaching to the nurses.

During the course of this complaint survey, it was discovered there was a lack of in-class or on-line orientation training which addressed how to appropriately perform detox assessments, signs and symptoms to look for, and when to provide interventions based on the assessments, to include when to notify the provider. Because nursing leadership had not investigated why new nurses lacked knowledge of how to appropriately perform CIWA and/or COWS assessments, this was not discovered prior to this complaint survey.

Review of Detox Assessments and Medication Orders

Review of the facility's CIWA assessment sheets currently used in the facility, and standing orders in the electronic Medication Administration Record (MAR) for detox of alcohol and opioids, revealed no parameters to guide the nurses when assessing or treating detox patients:

CIWA Assessment sheet

Review of the facility's CIWA-Ar assessment sheet, last revised 3/2015, revealed: ". . . Administer medications per Alcohol/Benzodiazepine Withdrawal Protocol orders based on patient's vital signs and total CIWA-Ar score. Notify MD [medical doctor] if vital signs and/or total CIWA-Ar score remain outside normal limits upon reassessment following medication administration . . ." In the section where nurses were to document which medications were given, it was titled "Meds [medications] given [more than] 9."

Further review of the CIWA-Ar assessment sheet revealed no guideline to show score ranges or what they meant, what medications to give when, or when to notify the provider.

COWS Assessment Sheet

Review of the facility's COWS assessment sheet, last revised 3/2015, revealed: ". . . Administer medications per Opioid Withdrawal Protocol orders based on patient's vital signs and [signs and symptoms] of opioid withdrawal. Notify MD if vital signs and/or withdrawal [signs and symptoms] remain outside normal limits upon reassessment following medication administration . . ." In the section where nurses were to document which medications were given, it was titled "Meds given [equal to more than] 15."

Further review of the COWS assessment sheet revealed total score interpretation scale, however there was no guidance on what medications to give when, or when to notify the provider.

Standing Orders

Review of the facility's "Guide: Order Sets for Admissions," undated, revealed order set for Adult Admission Orders; Admission Alcohol Acute Hospital Orders; and Admission Opiate Withdrawal Protocol orders. Further review revealed no parameters for PRN medication sets.

Review of the facility's policy "Detoxification Services," effective 5/2024, revealed: ". . . [facilities] are equipped to provide detoxification services that meet the unique needs of the medically compromised patient who had been under the influence of drugs and/or alcohol. The procedure below has been established to guide the provision of detox services. These general guidelines for these services include: 1. Treatment of medical symptoms of withdrawal will be individualized and is dependent on a thorough assessment. 2. The intensity of withdrawal cannot always be predicted accurately and requires: a. Close observation. b. Review of vital signs. c. Communication with the patient, family, and members of the treatment team. d. Knowledge of expected outcomes and potential negative symptoms. 3. Complete physical examination with special attention to neurologic signs. 4. Establish methods to track vital signs, medications, the presence and severity of physical symptoms, mood, and interaction with others. 5. Administration of medications as per detoxification protocols to prevent acute withdrawal symptoms and maintain physical comfort . . ."

QAPI and Adverse Events

During an interview on 8/15/24 at 12:42 PM, the Risk Manager and Quality Director stated that suicidal behavior, gesture, and attempt data, or the need for ED visits, were not tracked or analyzed by the facility's Performance Improvement (PI) committee (the facility's QAPI Program).

Review of the facility's "Quality Assurance [and] Performance Improvement (QAPI)" plan, dated 2024, revealed: ". . . The successful execution of the QAPI program is the result of the foundation of leadership commitment, education in performance improvement techniques, commitment of resources to execute improvement opportunities, information management systems for data display and comparisons and employee involvement in improving their own work processes . . . We believe important hospital processes and functions that perform well result in high quality patient care. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its systems and processes. The 2024 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes . .
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Based on interview and record review, the facility failed to ensure facility's Governing Body, medical staff, and administrative officials were responsible and accountable for ensuring that the hospital-wide Quality Assessment and Performance Improvement (QAPI) Program efforts addressed priorities for improved quality of care and patient safety specific to: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits. This failed practice placed all patient (based on a census of 63) at risk for injury, up to and including death, and/or substandard quality of care.

Findings:

Facility Risk Management and Quality Assurance Oversignt

During an interview on 8/13/24 at 10:47 AM, the Risk Manager stated the Patient Safety Council meetings were completed once a month and the Chief Executive Officer (CEO), Chief Operations Officer (COO), Risk Manager, Chief Nursing Officer (CNO), Medical Director, and Assistant Chief Nursing Officer (ACNO) attended the meetings. The Risk Manager further stated that the Quality Director's attendance was optional.

The Risk Manager stated that the Patient Safety Council measured and monitored the following items:

- Restraints/Seclusions rates;
- Patient injuries in restraints/seclusions;
- Patient aggression with and without injuries;
- Elopements;
- Falls;
- Medication variances (like medication errors or adverse reactions); and
- Patient safety alert advisory topics (these are presented to staff for reminders to help assure safety. Example: keep keys and badges secure)

Review of facility Patient Safety Council meeting minutes, dated 1/2024 through 6/2024, revealed no measurements or monitoring for suicide behavior, gestures, or attempts or patient ED visits.

During an interview on 8/13/24 at 12:09 PM, the Quality Director stated patient safety council meeting minutes were shared in the facility's Performance Improvement (PI) committee (the facility's QAPI Program), and that the PI committee only monitored performance tasks.

When asked how information was shared with the Governing Body (or Governing Board), the Quality Director stated that the same facility members who attended the Patient Safety Council also attended the PI committee meetings. The Governing Body consisted of the CEO and the Medical Director, and they took what was discussed in both the Patient Safety Council and the PI meetings into the Medical Executive Committee (MEC) meetings. Because the CEO and the medical Director were the Governing Board, they already knew the information from those meetings.

The Quality Director further stated that she would determine if anything from the PI committee needed to be presented to the Governing Body. When asked if anything had been brought to the Governing Body during this 2024 year, the Quality Director stated nothing had been brough forward.

Review of the facility's "BH [Behavioral Health] Performance Indicator Database - Acute" list, undated, revealed the list included "Suicide Risk Assessment/Management" which measured: "Compliance with initial suicide risk assessment; overall suicide risk level documented and proper mitigation taken based on risk level; do precautions march risk level; discharge education provided based on risk."

Further review of the performance indicator list revealed no monitoring of suicide behavior, gesture, or attempts or patient ED visits.

During an interview on 8/15/24 at 12:42 PM, the Risk Manager and Quality Director stated that suicidal behavior, gesture, and attempt data, or the need for ED visits, were not tracked or analyzed by the facility's Performance Improvement (PI) committee (the facility's QAPI Program).

Review of the facility's "Quality Assurance [and] Performance Improvement (QAPI)" plan, dated 2024, revealed: ". . . The successful execution of the QAPI program is the result of the foundation of leadership commitment, education in performance improvement techniques, commitment of resources to execute improvement opportunities, information management systems for data display and comparisons and employee involvement in improving their own work processes . . . We believe important hospital processes and functions that perform well result in high quality patient care. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its systems and processes. The 2024 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes . . ."

Review of the facility's "Bylaws of the Board of Governors of North Star Behavioral Health System," undated, revealed: ". . . The board shall be accountable for the safety and quality of care, treatment and services of the Hospital . . . The principal duties and responsibilities of the Board shall be to . . . ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Hospital . . . Make recommendations to the CEO/Managing Director and the Corporate Entity regarding support systems for quality assessment/performance improvement and risk management . . ."
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Based on record review and interview, the facility failed to meet the Condition of Participation of Nursing Services in accordance with CFR 482.23. The facility failed to comply with Federal requirements to have an organized nursing service that provided 24-hour nursing services to meet the needs of all patients through adequate, competent, and complete delivery of care.

Findings:

1) Based on record review and interview, the facility failed to ensure that facility admission assessments were completed for 10 patients (#s 1; 2; 3; 4; 9; 11; 15; 18; 23; and 26), out of 25 sampled patients. Specifically, the "Nursing Admission Assessment" and/or the assigned section of the "Standardized Intake Assessment" were not completed by Licensed Nurses (LNs) in their entirety for a full, completed, and accurate assessment. This failed practice placed all patients (based on a census of 63) at risk for not receiving necessary and/or appropriate medical, psychological, or psychosocial care, services, and treatments, to include treatment planning, during their inpatient programming due to the lack of consistent, accurate, and timely admission screenings/assessments. (Refer to A-395).

2) Based on record review and interview, the facility failed to ensure initial treatment plans were implemented for 2 patients (#s 9 and 26), out of 13 sampled patients actively admitted in the facility. Without timely treatment plans, to identify patient's mental, medical, and psychosocial needs, and create measurable interventions to meet these needs, these patients were at risk of not receiving the necessary and/or appropriate care and services to ensure patient safety and well-being. (Refer to A-396).

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

1) All licensed nurses (LNs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients;

2) All Mental Health Specialists (MHSs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients; and

3) LNs who worked in the adult substance abuse programs received education and training on how to appropriately conduct and interpret detoxification assessments (detox - a structured approach to safely remove toxins or harmful substances from the body) and provide interventions based on those assessments, to include when to administer medications and when to notify a doctor.

Specifically, the facility failed to ensure accurate interpretation and implementation of detoxification assessments and treatments for 1 Patient (#8), out of 14 detox patients reviewed, which resulted in an adverse event and required emergent higher level of care and hospitalization.

This failed practice regarding detoxification assessments and interventions placed all adult patients actively participating in withdrawal protocols (based on a census of 5) at risk for complications during their detoxification process. The failed practices regarding orientational training of LNs and MHSs placed all patients (based on a census of 63) at risk for subquality of care.

On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the Nursing Leadership's failure to ensure the operation of nursing services provided accurate substance abuse withdrawal assessments and appropriate and timely interventions to ensure patient safety.

The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM.

Implementation of the removal plan was verified on 8/19/24. The immediacy was removed on 8/19/24 at 1:27 PM.

Following the removal of the immediacy, noncompliance remained that was not immediate. (Refer to A-397).
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Based on record review and interview, the facility failed to ensure that facility admission assessments were completed for 10 patients (#s 1; 2; 3; 4; 9; 11; 15; 18; 23; and 26), out of 25 sampled patients. Specifically, the "Nursing Admission Assessment" and/or the assigned section of the "Standardized Intake Assessment" were not completed by Licensed Nurses (LNs) in their entirety for a full, completed, and accurate assessment. This failed practice placed all patients (based on a census of 63) at risk for not receiving necessary and/or appropriate medical, psychological, or psychosocial care, services, and treatments, to include treatment planning, during their inpatient programming due to the lack of consistent, accurate, and timely admission screenings/assessments.

Findings:

LN Admission Process

The facility's LNs were responsible for accepting newly admitted patients and complete a "Nursing Admission Assessment." This assessment reviewed the following areas:

- "Demographic Information;
- Admitting Vital Signs;
- Allergies;
- Reason for Admission;
- History of Present Illness;
- Medical History;
- Medical Condition Patient/Family Educational Needs;
- Infection Disease Screening;
- Tobacco Use Screening;
- Suicide Risk Assessment;
- Substance Abuse Assessment;
- Sexually Aggressive Behavior;
- Potential for Sexual Victimization;
- Homicidal/Violence/Aggression Risk Assessment;
- Elopement Risk Assessment;
- Psychological Trauma History;
- Heightened Risk Associated with Potential Restrain/Seclusion Intervention;
- Sleep History;
- Berlin Questionnaire (to screen for obstructive sleep apnea)
- Functional Assessment [to determine level of dependence for eating, bathing, dressing/grooming, toileting, ambulation, transferring, or assistive devices];
- Nutritional Screening;
- Pasero-Opioid Induced Sedation Scale (POSS) Baseline [to screen for possible sedation that could compromise breathing];
- Fall Risk;
- Learning Readiness and Preferences;
- Mental Status Assessment;
- Review of (body) systems;
- Skin Assessment;
- Patient Orientation [to the unit and program];
- Pain Assessment; [and]
- Nursing Admission Narrative Summary."

Different formats of Nursing Admission Assessments were used through the facility's different programs and had an extra section titled, "Summary Risk Assessment Treatment Interventions" which summarized risks for suicide/self-injury; fall risk; assault/homicide; homicide; seizure; medically compromised; elopement; sexual victimization risk; and sexual aggression risk.

The LNs also completed a section within the "Standardized Intake Assessment," which was completed by the admission's office Intake Staff, that the LN completed. This section was titled, "Interventions implemented following discussion with provider (to be completed by Unit RN)." Within this section, the LN was to document:

- "Observation Level;"
- "Provider's clinical justification for choosing Q15 [every 15 minutes] observations for patients at higher risk;" and
- "Other Interventions - Check all interventions that apply below which will be implemented to maintain safety of patient. Interventions chosen must be added to the Treatment Plan."

Review of the "Other Interventions" list revealed the following options:

- "Linen restriction - No additional linens in room;
- Plastic silverware and paper products for plates/bowls;
- Daily Contraband checks;
- RN to complete cheek check after every med [medication] pass [administration];
- Patient will have a roommate;
- Bathroom supervision;
- Ensure all staff know any special anniversary dates that may be difficult for patient (specify date and reason);
- Observe for any command hallucination and report to RN/medication nurse for prn [as needed] medications;
- Clothing restriction - no more than [space to add number] setts of clothes in room;
- Finger foods;
- Patient cannot have pencils or utensils unobserved;
- Room close to nurses station;
- Unit Restriction;
- Monitor patient response to phone calls/visitations;
- Monitor patient for any isolation;
- Strict adherence to no room time except during hours of sleep;
- Observe for resistance to answering questions during suicide reassessments; [and]
- N/A [not applicable]."

Further review of the section revealed: "By signing this document, the RN completing the Nursing Assessment/Admission attests they reviewed the Initial Suicide Risk Assessment above and will implement appropriate interventions determined by provider to maintain safety of patient." There was a place directly below for the LN to sign, print, date, and time this assessment.

Medical Record Review

Record review on 8/8-19/24 revealed the follow incomplete LN assessments:

Patient #1

Record review on 8/8/24 at 4:00 PM, revealed Patient #1 was admitted on 6/28/24 for alcohol dependence.

Further review revealed his/her "Nursing Admission Assessment," dated 6/28/24, was incomplete. The following assessment sections were not completed:

- Psychosocial Trauma History;
- Sleep History;
- Berlin Questionnaire; and
- Functional Assessment.

Patient #2

Record review on 8/8/24 at 4:05 PM, revealed Patient #2 was admitted on 6/13/24 for alcohol dependence.

Further review revealed his/her "Nursing Admission Assessment," dated 6/13/24, was incomplete. The following assessment sections were not completed, or only partially completed:

- Homicidal/Violence/Aggression Risk Assessment;
- Fall Risk Assessment;
- Learning Readiness and Preferences; and
- Patient orientation;

Patient #3

Record review on 8/8/24 at 4:12 PM, revealed Patient #3 was admitted on 7/9/24 for opioid dependence and other stimulant dependence.

Further review revealed his/her "Nursing Admission Assessment," dated 7/10/24, was incomplete. The following assessment sections were not completed, or only partially completed:

- Allergies;
- Reason for Admission;
- History of Present Illness;
- Fall Assessment;
- Review of Systems (skin integrity section);
- Patient Orientation; and
- Pain Assessment.

Patient #4

Record review on 8/8/24 at 4:20 PM, revealed Patient #4 was admitted on 7/22/24 for alcohol dependence.

Further review revealed the LN's section on the "Standardized Intake Assessment," dated 7/22/24, was incomplete. The following assessment sections were not completed:

- Observation Level; and
- Provider's clinical justification for choosing Q15 observations for patients at higher risk.

Patient #9

Record review on 8/9/24 at 11:30 AM, revealed Patient #9 was admitted on 7/22/24 for post-traumatic stress disorder (PTSD).

Further review revealed his/her "Nursing Admission Assessment," which was not dated, was incomplete. The following assessment sections were not completed, or only partially completed:

- Skin Assessment;
- Patient Orientation;
- History of Present Illness;
- Berline Questionnaire;
- Suicide Risk Assessment;
- Fall Risk Assessment;
- Summary Risk Assessment Treatment Interventions; and
- The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment.

Review of Patient #9's "Standardized Intake Assessment," dated 7/17/24 was incomplete. The sections entire section for the LN to completed was blank. Further review revealed the LN did not sign, date, or time this assessment section.

Patient #11

Record review on 8/12/24 at 2:05 PM, Patient #11 was admitted on 7/12/24 for unspecified psychosis not due to a substance.

Further review revealed his/her "Nursing Admission Assessment," which was not dated, was incomplete. The following assessment sections were not completed, or only partially completed:
- Allergies;
- Skin Assessment;
- Infectious Disease Screening;
- Nutritional Screen;
- Fall Risk Assessment;
- Substance Abuse Assessment;
- Mental Status Assessment;
- Suicide Risk Assessment;
- Potential for Sexual Victimization;
- Sexually Aggressive Behavior;
- Homicidal/Violence/Aggression Risk Assessment;
- Psychological Trauma History;
- Elopement Risk Assessment;
- Heightened Risk Associated with Potential Restraint/Seclusion Intervention;
- Medical Condition Patient/Family Educational Needs;
- Summary Risk Assessment Treatment Interventions; and
- The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment.

Patient # 15

Record review on 8/12/24 at 1:36 PM, Patient #15 was admitted on 4/18/24 through 5/14/24 for major depressive disorder single episode, severe without psychotic features.

Further review revealed his/her "Nursing Admission Assessment," dated 4/18/24, was incomplete. The Berlin Questionnaire section was not completed.

Further review revealed the LN's section on the "Standardized Intake Assessment," dated 4/18/24, was incomplete. The following assessment section was not completed:

- Provider's clinical justification for choosing Q15 observations for patients at higher risk.

Patient #18

Record review on 8/12/24 at 11:52 AM, Patient #18 was admitted on 7/22/24 through 8/1/24 for alcohol dependence.

Further review revealed his/her "Nursing Admission Assessment," dated 7/22/24, was incomplete. The following assessment sections were not completed, or only partially completed:

- Allergies;
- Berlin Questionnaire;
- Nutritional Screen;
- Learning Readiness and Preferences;
- Skin Assessment;
- Patient Orientation;
- Pain Assessment; and
- The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment.

Further review revealed the LN's section on the "Standardized Intake Assessment," dated 7/22/24, was incomplete. The following assessment section was not completed:

- Observation Level;
- Provider's clinical justification for choosing Q15 observations for patients at higher risk; and
- Other Interventions - Check all interventions that apply below which will be implemented to maintain safety of patient. Interventions chosen must be added to the Treatment Plan.

The LN signed this section but did not complete it.

Patient #23

Record review on 8/12/24 at 11:00 AM, revealed Patient #23 was admitted 7/22/24 through 7/24/24 for alcohol dependence.

Further review revealed the LN's section on the "Standardized Intake Assessment," dated 7/22/24, was incomplete. The following assessment sections were not completed:

- Observation Level; and
- Provider's clinical justification for choosing Q15 observations for patients at higher risk.

Patient #26

Record review on 8/12/24 at 11:10 AM, Patient #26 was admitted 8/2/24 for PTSD and reactive attachment disorder (RAD).

Further review revealed his/her "Nursing Admission Assessment," was not dated and was incomplete. The following assessment sections were not completed, or only partially completed:

- Skin Assessment;
- History of Present Illness;
- Berlin Questionnaire;
- Nutritional Screen;
- Pasero-Opioid-Induced Sedation Scale Baseline;
- Fall Assessment;
- Substance Abuse Assessment;
- Mental Status Assessment;
- Suicide Risk Assessment;
- Potential for Sexual Victimization;
- Sexually Aggressive Behavior;
- Psychological Trauma History;
- Elopement Risk Assessment;
- Heightened Risk Associated with Potential Restraint/Seclusion Intervention;
- Medial Condition Patient/Family Educational Needs;
- Summary Risk Assessment Treatment Interventions; and
- The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment.

During an interview on 8/12/24 at, 3:40 PM, the Medical Director stated nursing admission assessment forms had a history of not being completed consistently. The Medical Director stated that she had verbally reported the incomplete nursing admission assessment concern to the Assistant Chief Nursing Officer (ACNO).

During an interview on 8/14/24 at 11:52 AM, the ACNO stated all nursing admission assessments were to be completed within 24 hours of an admission.

When asked how medical record audits were completed to ensure all assessments reviewed to ensure they were completed, the ACNO stated audits were completed by the house supervisors three days per week. If a deficiency was identified, an email was sent to the admitting nurse to complete their missing documentation. The ACNO further stated that nursing admission assessment deficiencies were not communicated to the ACNO or the CNO.

During this interview, when asked how nursing leadership followed up to ensure deficiencies identified on nursing admission assessments were corrected, the ACNO did not give a definitive answer and could not be clearly identified.

During the survey, it was requested for the facility to provide proof of emails sent regarding deficiencies found during audits of admission nursing assessments. 18 emails were presented, however only two contained information regarding admission assessment audits. The remaining 16 emails were regarding nursing notes or observation sheets missing items.

Review of the facility policy "Patient/Resident Admission Procedures," effective date 6/2023, revealed: ". . . Registered Nurse will complete a nursing assessment . . . The receiving RN completes the initial treatment plan and admission note."

Review of the facility policy "Medical Record Documentation," last revised date 5/2023, revealed: ". . . Each entry is to be dated and timed. . . The medical record is a legal document. . . Empty spaces are not left in documentation. . . Entries are to be written legibly. All entries must include a legible signature, legal name (printed in block letters), and discipline. . ."
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Based on record review and interview, the facility failed to ensure Initial Treatment Plans (ITPs) were implemented for 2 patients (#s 9 and 26), out of 13 sampled patients actively admitted in the facility. Without timely treatment plans, to identify patient's mental, medical, and psychosocial needs, and create measurable interventions to meet these needs, these patients were at risk of not receiving the necessary and/or appropriate care and services to ensure patient safety and well-being.

Findings:

Patient #9

Record review on 8/9/24 at 11:34 AM, revealed Patient #9 was admitted on 7/22/24 for post-traumatic stress disorder (PTSD).

Further review revealed Patient #9's ITP was not completed and remained blank in the medical record. Patient #9's Master Treatment Plan was completed on 7/24/24, two days after admission. Patient #9 had no treatment plan for the first two days of admission.

Patient #26

Record review on 8/12/24 at 11:10 AM, revealed Patient #26 was admitted on 8/2/24 for PTSD and reactive attachment disorder (RAD).

Further review revealed Patient #26's ITP was completed on 8/5/24 (3 days after admission). Further review of the ITP documented instructions revealed the following guidance: ". . . The ITP must be completed within 24 hours. . ."

During interview on 8/13/24 at 8:30 AM, the Program Educator stated on Thursdays of the orientation week, nurses were orientated on the admission process. This included the completion of the Initial Treatment Plan within 24 hours.

Review of facility's policy, "IDT Patient Centered Planning- Acute", dated 7/2023, revealed, ". . . 3. Policy . . . North Star Behavioral Health Systems to provide therapeutic services based upon a patient-centered, individualized treatment plan . . . 4. Procedure . . . 1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission."

Review of facility's policy, "Patient/Resident Admission Procedures, PC191", dated 6/2023, revealed, ". . . 14. The receiving RN [Registered Nurse] completes the initial treatment plan and admission note."
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Based on record review and interview, the facility failed to ensure:

1) All licensed nurses (LNs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients;

2) All Mental Health Specialists (MHSs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients; and

3) LNs who worked in the adult substance abuse programs received education and training on how to appropriately conduct and interpret detoxification assessments (detox - a structured approach to safely remove toxins or harmful substances from the body) and provide interventions based on those assessments, to include when to administer medications and when to notify a doctor.

Specifically, the facility failed to ensure accurate interpretation and implementation of detoxification assessments and treatments for 1 Patient (#8), out of 14 detox patients reviewed, which resulted in an adverse event and required emergent higher level of care and hospitalization.

This failed practice regarding detoxification assessments and interventions placed all adult patients actively participating in withdrawal protocols (based on a census of 5) at risk for complications during their detoxification process. The failed practices regarding orientational training of LNs and MHSs placed all patients (based on a census of 63) at risk for subquality of care.

On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the Nursing Leadership's failure to ensure the operation of nursing services provided accurate substance abuse withdrawal assessments and appropriate and timely interventions to ensure patient safety.

The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM.

Implementation of the removal plan was verified on 8/19/24. The immediacy was removed on 8/19/24 at 1:27 PM.

Following the removal of the immediacy, noncompliance remained that was not immediate.

Findings:

Facility Programs

The facility consisted of three acute care inpatient programs totaling 140 beds:

1. The main building's program was an acute care behavioral health, psychiatric, inpatient program for children, preteens, and adolescents. The building had four units for patient care: 1) two 20-bed units (Alyeska and Denali) on the second floor for adolescents; 2) one 16-bed unit (Chena) on the third floor for children and preteens; and 3) one 18-bed unit (Kenai) on the third floor that was not currently a full time programmed unit, however was used for evening programming and sleeping for select adolescents from the second floor;

2. The Arctic Recovery Program was in a different building on the same campus as the main building. This 30-bed program offered acute inpatient care for adults and offered detox and rehabilitation for substance abuse to non-military adults; and

3. The Chris Kyle Patriot Hospital, which was at a different location in town. This 36-bed program offered acute inpatient care for adults and offered trauma-focused care and detox and rehabilitation for substance abuse for active military, veterans, and first responders.

1) Orientation Training Process for Nurses

The facility hired LNs through individuals who applied through the facility's positions posted to the public (applicant nurses) and through contract agencies that were associated with Universal Health Services, the facility's corporate branch (contract nurses).

Applicant Nurses

During an interview on 8/13/24 at 9:05 AM, the Senior Human Resources (HR) Generalist and Program Educator stated all applicant nurses, once they have completed the hiring process and have completed a background check, began the orientation process to work at the facility:

- The first week (Monday through Friday) consisted of onboarding for all new hires: Monday/Tuesday: initial orientation, meet leadership, and CPR (if needed); Wednesday: verbal de-escalation training: Thursday: Handle with Care training (de-escalation and manual hold techniques); and Friday: independent, on-line class trainings assigned on HealthStream (the facility's on-line education platform).

- The second week (Monday through Friday) was for LNs and MHSs called "Bootcamp." Monday: facility specific requirements - 1) how to fill out seclusion and restraint paperwork and every-15 (Q15) minute check sheets (monitoring sheets that accompany staff working with patients; staff were to be physically located and staff identified the patient's behavior, location, and position every 15 minutes of the day, 24 hours a day); 2) milieu management; 3) acute changes in condition; 4) normal vital signs and what to report to the LNs; 4) safety precautions and what they mean; Tuesday: Simulation scenario-based training, review Handle with Care.

Review of the facility's in-class orientation training curriculum during Bootcamp included:

- Acute Change of Condition [didn't include information on CIWA or COWS]
- Addiction Training [didn't include information on CIWA or COWS]
- Group Facilitation Training
- Initial Competency - RN (or MHS)
- Mileu Management Training
- North Star Onboarding - RN (or MHS)
- Nursing Department Management Review
- Precautions Training
- Q15 Attestation
- Q15 Observation Training
- Standard Safety Precautions

At this point, nurses would split off from MHS and complete training on nursing practice protocols the rest of the week: admission paperwork, initial treatment plans, paper charting and where to find things. Computer charting, on their HCS system, how to navigate the system and made sure they obtained computer accesses. There was a training entitled "QRN" where the face-to-face assessments for seclusion and restraints was reviewed, warning signs were also taught, and how to fill out the paperwork. Also, specific equipment was reviewed (needles, syringes, point of care testing supplies, epi pens, and AEDs). Friday was a catch-up day, to include finishing HealthStream trainings.

The Senior HR Generalist and Program Educator further stated that applicant nurses could not start job-specific orientation, called shadowing, on the units until all assigned HealthStream trainings were completed. Once completed, the applicant nurses would get two weeks (six 12-hour shifts) to shadow a senior nurse to learn the job through demonstration and direct patient care practice. During this shadowing orientation, the nurses completed two orientation check lists: 1) The "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" and 2) The "[facility] Onboarding Nurse Competencies During Orientation" checklist.

Review of the facility's orientation checklist, "[Facility] Initial Competency/Department Orientation Checklist, Registered Nurse," undated, revealed orientating nurses received education/training through demonstration, observation, being tested, or verbalization methods. The training component of skill sections included;

- Job description;
- Nursing responsibilities;
- Unit safety walkthrough;
- Patient appointments;
- Milieu management principles;
- Medication test/competency checklist;
- Pharmacy procedures;
- Admission procedures checklist;
- Discharge procedures/checklist;
- Daily nursing note and BIRP (Behavior, Intervention, Response, Plan charting method);
- Shift to shift reporting;
- Seclusion and restraint procedures/documentation;
- Writing a discharge note;
- Vitals;
- Observation checks;
- Emergency procedures/codes;
- Treatment team procedures/documentation;
- 1 2 3 magic test (behavior redirection technique);
- Group competency;
- Medication administration;
- Staff assignment sheet;
- In system consult/out of system consult;
- Activities of daily living/ADL's;
- Precautions;
- EMTALA (Emergency Medical Treatment and Active Labor Act);
- Intake Backup;
- MD orders and transcription;
- Searches (contraband/body searches);
- Attendance/call-in procedures;
- Time clock/Kronos; and
- Phone system.

Further review revealed this form had sections for both the preceptor and employee to make comments and then sign and date when the form was completed.

Review of the facility's orientation checklist "[facility] Onboarding Nurse Competencies During Orientation," undated, revealed orientating nurses received education/training in the following areas:

- AMA (against medical advice) Process;
- In facility consults;
- Out of facility consults;
- Patient assessment documentation;
- Admissions;
- Discharges;
- Initial treatment plan;
- Medical treatment plan and problem sheets;
- Q15 forms;
- General info-phone etiquette/phone binders;
- Pill cutters;
- Code red response;
- Treatment team;
- Daily documentation;
- Seclusion and restraint;
- Contraband searches;
- Environment of care (form);
- Incident reports/Midas (incident reporting computer program);
- COWS (Clinical Opiate Withdrawal Scale)/CIWA (Clinical Institute Withdrawal Assessment for Alcohol) forms (as needed);
- Breathalyzer competency;
- Omnicell Access/Medication Administration;
- Precautions;
- Suicide Risk Assessment;
- Narcan Administration (medication to administer for opioid overdose);
- Bedsheet/How to use;
- Chart checks;
- Home medications;
- Code Blue (forms and bags);
- Cutter tool competency;
- Epi pens;
- Glucometer;
- POC (point of care) testing (drug testing/strep/pregnancy);
- EKG (electrocardiogram);
- Oxygen administration;
- Specimen collection (MRSA, COVID-19);
- Unit assignment sheets (coverage for codes, lunch, breaks);
- Vital signs/vital signs form;
- Code intervention response; and
- Tour.

Further review revealed a box to check that "ALL HealthStream Completed" and a place for a manager or educator to sign. The following attestation was also on the onboarding form, "I [nurse's name], acknowledge and agree that I have been trained in the above stated trainings and will adhere to the agency policies and Safety procedures to [ensure] patient and staff safety at all times. I have received and read the Orientation materials. I agree to abide by all Hospital Policies and Procedures. I understand that it is my responsibility to follow up with any questions related to this information with a representative of the Human Resources Department or my immediate supervisor. Any incidents or safety issues will be reported during my working shift. Other concerns will be brought to my immediate supervisor." The employee printed their name, signed and dated this attestation.

Applicant Nurses Orientation Review

Random personnel record reviews, on 8/13-14/24, revealed that applicant nurse's orientations were missing components of the orientation expectations presented by the Senior HR Generalist and Program Educator.

LN #2

Review of LN #2's personnel record, on 8/13/24, revealed:

- LN #2 was hired 7/2022.
- LN #2's record revealed he/she completed his/her shadowing shifts on 8/2-5/22. Further review revealed LN #2 didn't complete his/her "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse" checklist until 3/23/23 (230 days after his/her shadowing shifts).

LN #8

Review of LN #8's personnel record, on 8/13/24, revealed:

- LN #8 was hired 10/16/23.
- LN #8's record revealed he/she completed his/her shadowing shifts on 10/30/23 - 11/3/23. Further review revealed LN #8 didn't complete his/her "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse" checklist until 1/15/24 (73 days after his/her shadowing shifts).

During an interview on 8/12/24 at 4:45 PM, LN #8 stated when he/she went through the orientation training, and was assigned to work the Arctic Recovery program, he/she wasn't even aware there were adult programs at the facility. LN #8 stated that orientation was focused on the children, preteen, and adolescent programs and not the adults. There was no detox training, and he/she had no experience with withdrawal symptoms or the detox assessments.

LN #30

Review of LN #30's personnel record, on 8/13/24, revealed:

- LN #30 was hired 3/18/24.
- LN #30's record revealed he/she completed his/her shadowing shifts on 4/3-10/24. Further review revealed LN #30 didn't complete his/her "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse" and "[facility] Onboarding Nurse Competencies During Orientation" checklists until 5/7/24 (25 days after his/her shadowing shifts).

LN #41

Review of LN #41's personnel record, on 8/14/24, revealed:

- LN #41 was hired 4/29/24.
- LN #41's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" or "[facility] Onboarding Nurse Competencies During Orientation" checklists.

LN #46

Review of LN #46's personnel record, on 8/13/24, revealed:

- LN #46 was hired 8/22/22.
- LN #46's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" or "[facility] Onboarding Nurse Competencies During Orientation" checklists.

Contract Nurses

There were two contract agencies currently used by the facility: 1) Horizon Health, or Adventure RN; and 2) Supplemental Health Care.

During an interview on 8/13/24 at 9:05 AM, the Senior HR Generalist and Program Educator stated all contract nurses, once they have completed the hiring process and have completed a background check, began the orientation process to work at the facility. The contract nurses completed the first week of onboarding that consisted of completing verbal de-escalation, Handle with Care, and CPR. The contract nurses would not complete "Bootcamp" like applicant nurses, and instead completed a bridged orientation in QRN training, chart paperwork, equipment, and safety precautions.

Once these orientation trainings were completed, contract nurses were provided with one 12-hour shadow shift and also were required to complete the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" and "[facility] Onboarding Nurse Competencies During Orientation" checklists.

During an interview on 8/14/24 at 2:30 PM, the Quality Director and Program Educator stated contract nurses were also assigned independent, on-line class trainings on HealthStream, however their assignment set differed from applicant nurses and, depending on which contract agency they came from, had a different assignment set per agency (Horizon Health, Adventure RN contract nurses were to be assigned 35 trainings and Supplemental Health Care contract nurses were to be assigned 54 trainings).

The Program Educator further stated contract nurses didn't have a timeline to complete their assigned HealthStream training and were "due when they get it done." The contract nurses would start working with patients after their shadow orientation day, regardless of whether their HealthStream training was completed or not.

Contract Nurses Orientation Review

The facility currently had six contract nurses working at the facility:

- LN #'s 22, 27, and 32 were contract nurses with Horizon Health, Adventure RN; and
- LN #s 11, 16, and 39 were contract nurses with Supplemental Health Care.

Random reviews, on 8/13-14/24, revealed that each contract nurse's orientations were missing components of the orientation expectations presented by the Senior HR Generalist and Program Educator.

Horizon Health, Adventure RN Contract Nurses

LN #22

Review of LN #22's personnel record, on 8/14/24, revealed:

- LN #22 was hired 7/22/24.
- LN #22's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" or "[facility] Onboarding Nurse Competencies During Orientation" checklists.
- LN #22 was assigned 55 HealthStream trainings.

Further review revealed LN #22 had five incomplete HealthStream trainings, which included pain management, patient safety discharge process, and trauma informed care.

LN #27

Review of LN #27's personnel record, on 8/13/24, revealed:

- LN #27 was hired 7/15/24.
- LN #27's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse" checklist.
- LN #27 was assigned 46 HealthStream trainings.

Further review revealed LN #27 had seven incomplete HealthStream trainings, which included suicide assessment and reassessment, suicide prevention, and pain management.

LN #32

Review of LN #32's personnel record, on 8/14/24, revealed:

- LN #32 was hired 8/5/24.
- LN #32 was still completing shadowing shifts and his/her orientation checklists were pending.
- LN #32 was assigned the following 49 HealthStream trainings:

Further review revealed LN #32 had five incomplete HealthStream trainings, which included schizophrenia and psychotic disorders and pain management.

Supplemental Health Care Contract Nurses

LN #11

Review of LN #11's personnel record, on 8/13/24, revealed:

- LN #11 was hired 6/10/24.
- LN #11's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" or "[facility] Onboarding Nurse Competencies During Orientation" checklists.
- LN #11 was assigned 33 HealthStream trainings.

Further review revealed LN #11 had 21 incomplete HealthStream trainings, which included assessing and managing suicide risk units 1-3; key points in crisis management; discharge planning 4 - safety planning; and precautions and prevention of high-risk behaviors.

During an interview on 8/11/24 at 1:16 AM, LN #11 stated he/she had never worked acute detox or a psychiatric hospital before and agreed that the orientation could have been more focused on working the acute adult programs. LN #11 stated there was no orientation to detox protocols or assessments.

LN #16

Review of LN #16's personnel record, on 8/14/24, revealed:

- LN #16 was hired 7/22/24.
- LN #16's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" or "[facility] Onboarding Nurse Competencies During Orientation" checklists.
- LN #16 was assigned 40 HealthStream trainings.

Further review revealed LN #16 had two incomplete HealthStream trainings, which were about patient safety discharge process and suicide assessment/reassessment.

LN #39

Review of LN #39's personnel record, on 8/13/24, revealed:

- LN #39 was hired 7/8/24.
- LN #39's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" or "[facility] Onboarding Nurse Competencies During Orientation" checklists.
- LN #39 was assigned 44 HealthStream trainings.

Further review revealed LN #39 had 19 incomplete HealthStream trainings, which included suicide assessment and reassessment.

Review of facility's orientation curriculum training form, "Nursing Department Management Review," undated, revealed: ". . . Continuing Education. . . Education is provided through various platforms, including: Health Stream and in-person classroom. Caregivers, including travelers, are required to complete assigned education by their due dates, or they will be removed from the schedule." Further review revealed the form had an acknowledgement statement, "I acknowledge I have received this information and will be accountable to adhering to the expectations outlined" and this form was signed and dated by the employees.

2) Orientation Training Process for MHS

Review of the facility's orientation training for MHS revealed the same hiring and orientation training process. After Bootcamp, however, they split off from the nurses and completed MHS specific training.

During an interview on 8/13/24 at 9:05 AM, the Senior HR Generalist and Program Educator stated MHS staff would get one week (five 8-hour shifts) to shadow a senior MHS staff to learn the job through demonstration and direct patient care practice. During this shadowing orientation, the MHS completed two orientation check lists: 1) The "[facility] Initial Competency/Department Orientation Checklist, MHS;" and the "[facility] Onboarding Mental Health Specialists Competencies During Orientation" checklists.

Review of the facility's orientation checklist, "[Facility] Initial Competency/Department Orientation Checklist, MHS," undated, revealed orientating MHS staff received education/training through demonstration, observation, being tested, or verbalization methods. The training component of skill sections included;

- Job description;
- MHS responsibilities;
- Unit safety walkthrough;
- Attendance/call-in procedures;
- Time clock/Kronos; and
- Phone system.

Further review revealed this form had sections for both the preceptor and employee to make comments and then sign and date when the form was completed.

Review of the facility's orientation checklist "[facility] Onboarding Mental Health Specialists Competencies During Orientation," undated, revealed orientating MHS staff received education/training in the following areas:

Day 1:
- General info-phone etiquette/phone binders;
- Overhead pages;
- Vital signs/vital signs form;
- Q15 Sheet
- Bedsheet/How to use; and
- Tour of Units (as needed).

Day 2:
- Transitioning from one activity to another (i.e., lunch, gym, visitation);
- Cutter Tool Competency;
- Linen (storage and limit use)/Laundry room protocol;
- Shift to Shift/Handoff; and
- Code Red Response.

Day 3:
- Hygiene Bins/Protocol;
- Precautions;
- 1:1 [one-to-one]/Seclusion Observation; and
- Incident Reports/Midas.

Day 4:
- Reporting to Nurse;
- Code Blue Response;
- Patient belongings/Inventory; and
- Contraband Searches.

Day 5:
- Environmental Rounds/Environment of Care;
- Intervention Response;
- Night Rounds; and
- Hallway Presence.

Behaviors:
- Recognizes signs of escalation;
- Builds rapport with patients;
- Collaborates with peers;
- Recognizes potential safety hazards;
- Actively listens to patients;
- Maintains appropriate boundaries; and
- Demonstrates limit-setting.

Further review revealed a box to check that "ALL HealthStream Completed," a statement, "During you shadow experience, work on building rapport with the patients, verbal de-escalation and learning the routines of the unit," and a place for a manager or educator to sign. The following attestation was also on the onboarding form, "I [nurse's name], acknowledge and agree that I have been trained in the above stated trainings and will adhere to the agency policies and Safety procedures to [ensure] patient and staff safety at all times. I have received and read the Orientation materials. I agree to abide by all Hospital Policies and Procedures. I understand that it is my responsibility to follow up with any questions related to his information with a representative of the Human Resources Department or my immediate supervisor. Any incidents or safety issues will be reported during my working shift. Other concerns will be brought to my immediate supervisor." The employee printed their name, signed and dated this attestation.

MHS Orientation Review

Random personnel record reviews, on 8/13/24, revealed that MHS's orientations were missing components of the orientation expectations presented by the Senior HR Generalist and Program Educator.

MHS #3

Review of MHS #3's personnel record, on 8/13/24, revealed:

- MHS #3 was hired 3/6/24.
- MHS #3 completed his/her shadow shifts on 3/13-22/24. Further review revealed MHS #3 didn't complete his/her "[facility] Initial Competency/Department Orientation Checklist, MHS" checklist until 4/2/24 (11 days after his/her shadowing shifts).

MHS #15

Review of MHS #15's personnel record, on 8/13/24, revealed:

- MHS #15 was hired 6/24/24.
- MHS #15's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, MHS" checklist.

MHS #61

Review of MHS #61's personnel record, on 8/13/24, revealed:

- MHS #61 was hired 5/2024.
- MHS #61's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, MHS;" or "[facility] Onboarding Mental Health Specialists Competencies During Orientation" checklists.

During an interview on 8/11/24 at 12:40 AM, MHS #61 stated he/she felt the hire orientation training was focused on working at the acute inpatient children, preteen, and adolescent units and did not provide any adult or detox orientation. MHS #61 stated he/she had to try and learn about detox during shadowing days which was a challenge. MHS #61 further stated that in his/her experience all MHS staff, who are new and the work adult units after shadowing, still don't know anything about the unit. They didn't know the rules, where anything was, or about detox signs. As MHS staff, MHS #61 stated that they "learn as we go together" and "wing it" on the job until it becomes familiar.

MHS #82

Review of MHS #82's personnel record, on 8/13/24, revealed:

- MHS #82 was hired 3/2024.
- MHS #82's record didn't contain the "[facility] Onboarding Mental Health Specialists Competencies During Orientation" checklist.
- MHS #82 completed his/her shadow shifts on 4/2-6/24. Further review revealed MHS #82 didn't complete his/her "[facility] Initial Competency/Department Orientation Checklist, MHS" checklist until 4/18/24 (12 days after his/her shadowing shifts).

MHS #94

Review of MHS #94's personnel record, on 8/13/24, revealed:

- MHS #94 was hired 3/2024.
- MHS #94's record didn't contain the "[facility] Initial Competency/Department Orientation Checklist, MHS" checklist.

MHS #100

Review of MHS #100's personnel record, on 8/13/24, revealed:

- MHS #100 was hired 3/4/24.
- MHS #100 completed his/her shadow shifts on 3/19-23/24. Further review revealed MHS #100 didn't complete his/her "[facility] Initial Competency/Department Orientation Checklist, MHS" checklist until 8/13/24 (143 days after his/her shadowing shifts).

During an interview on 8/12/24 at 4:45 PM, LN #8 stated he/she felt that new MHS orientation training was insufficient because when they started working on the units, they were unfamiliar with their roles.

During an interview on 8/13/24 at 9:37 AM, the Quality Director stated the facility acknowledged they could do a better job on documentation in personnel records.

Detox Assessment and Implementation (Immediate Jeopardy)

Detox Protocol

During the detox process, nurses monitored newly admitted patients through their withdrawal symptoms and provided scheduled and PRN (as needed) medications and treatments to help safely guide them through detoxing from alcohol and/or opioids (narcotic medications). Two assessment forms were used:

1. Alcohol Withdrawal - A Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) form; and
2. Opioid Withdrawal - A Clinical Opiate Withdrawal Scale (COWS) form.

The detox monitoring usually started upon admission and was completed every 4 hours, then graduated to every 6 hours and then every 8 hours, depending on how individual patients responded to detoxing. These assessments entailed obtaining vital signs and rating the patient's symptoms on severity scales. A total score would be ascertained at every assessment, and based on that total score medications would be administered and treatments would be implemented.

7/31/24 Incident

During an interview on 8/12/24 at 5:31 PM, LN #7 stated he/she had picked up an extra shift on Arctic Recovery, which started at 11:00 PM. When he/she arrived, it was discovered that Patient #8 was newly admitted for alcohol dependence and was experiencing distressing withdrawal symptoms. When LN #7 talked with the nurses who were currently working, LNs #30 and #41, it was discovered the nurses had not provided withdrawal PRN medication interventions, since admission because they thought it was facility policy that they could not provide medications if the patient's blood alcohol level was still elevated and not within the legal limit (0.08 in Alaska), which was not the case. LN #7 stated he/she began to assess Patient #8. His/her blood alcohol level was 0.11 and he/she was shaking to the point that a wheelchair was required to transfer the patient to his/her bedroom. LN #7 initiated PRN medication interventions, of Ativan (an antianxiety medication) and attempted to get the patient's symptoms under control, however, could not. At around 5:00 AM, LN #7 called the provider on-call and received orders to have the patient transferred to the ED. The patient was subsequently admitted to the hospital. LN #7 further stated that an incident report was filed, and he/she reported to nursing leadership of the concern that these newer nurses were not administering detox protocols appropriately which may have contributed to Patient #8's decline and need for emergent higher level of care.

Review of Patient #8's medical record, dated 7/31/24 through 8/1/24, revealed the following information:

- Patient #8's blood alcohol level upon admission, on 7/31/24 at 10:15 AM, was 0.36 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled "Alcohol's Effects on Health", dated January 2023 reveal a level between 0.31 to 0.45 is considered life threating and may contribute to unconsciousness and significant risk of death due to suppression of vital life functions.)
- Patient #8 had a history of seizures, the last seizure occurred in 5/2023.
- During the admission process, Patient #8 had vomited and was sent over to the ED for medical clearance prior to being admitted. Patient was medically cleared and returned to the facility around 5:00 PM.
- At 5:00 PM, Patient #8's CIWA score was 9 (which indicated minimal to mild withdrawal), however was rated as having visible tremors, more than mildly anxious, and had beads of sweat obvious on his/her forehead. No medication intervention was documented as given.
- At 6:00 PM, his/her blood alcohol level was 0.27 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled "Alcohol's Effects on Health", dated January 2023 reveal a level between 0.15 to 0.30 is considered severe impairment and may contribute to confusion, vomiting, drowsiness, and unconsciousness.)
- At 8:00 PM, Patient #8's CIWA score was 10 (which still indicated minimal to mild withdrawal), however his/her symptoms were more increased: mildly nauseous, tremors were less, mildly anxious, beads of sweat were still visible on forehead, and had a mild headache or fullness in head. LN #30 documented "1.9 BRAK [blood alcohol level] scheduled" where medications were to be listed if given. Medications that were given was gabapentin (An anticonvulsant medication used for seizures, nerve pain, and restless legs) at 8:38 PM, Seroquel at 8:39 PM, and Tylenol at 8:40 PM.
- Once LN #7 was on shift, he/she took over Patient #8's care.
- At 12:00 AM, Patient #8's CIWA score was 9, with elevated anxiety and headache, and LN #7 administered Tylenol and Ativan by mouth.
- At 3:10 AM, Patient #9's CIAWA score remained 9, however Patient #8's anxiety increased. Ativan was again administered by mouth.
- At 4:30 AM, Patient #8's CIWA score was 18 (which indicated severe withdrawal), and Ativan was administered via injection. When this was not effective, LN #7 notified the provider and the decision was made to transport the patient to the ED. Patient #8 left, with a staff escort and EMS at 5:50 AM.
Patient #8 was without withdrawal PRN medication treatment for approximately 6 hours prior to LN #7 arriving for work.

Patient #8 was admitted to the hospital.

LN Interviews

During an interview on 8/12/24 at 4:24 PM, Licensed Nurse (LN) #2 stated new nurses completed an in-class structured orientation, and after this would have 2 to 3 shadow days with a nurse to learn the role. After this, new nurses were assigned a shift and put into direct patient care. LN #2 stated that from his/her experience in working with newly hired nurses, they weren't prepared and didn't know where things were or how to appropriately monitor detox patients.

During an interview on 8/12/24 at 4:45 PM, LN #8 stated newly hired nurses didn't know their roles after they completed orientation and shadow days. Experiencing orientation when hired, LN #8 stated he/she had no detox training at orientation and hadn't known about withdrawal symptoms from alcohol or substances, how to perform CIWA (shortened version of CAIW-Ar) or COWS screenings, and what the scores meant.

Detox Orientation Training

Review of the facility's current detox orientation training, on 8/8-19/24, revealed:

- The "[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;" checklist did not contain any training component of skill for detox protocol on how to conduct, interpret, or implement detox assessments and treatments.

- The "[facility] O

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Based on interview and record review, the facility failed to ensure medical records contained information to describe the patient's progress and response to services. Specifically, the facility failed to ensure Mental Health Specialists (MHSs - direct patient care staff working daily with patients within the program environment) had access to document in the medical record. This failed practice placed all patients (based on a census of 63) at risk for not having documentation of daily witnessed interactions and behaviors, as well as interventions received by MHS staff in their medical records, which had the potential to limit appropriate services and/or treatments needed to address their medical, psychological, and psychosocial needs.

Findings:

During an interview on 8/8/29 at 4:04 PM, Licensed Nurse (LN) #10 stated MHS no longer complete daily progress note charting. LN #10 was unsure of the rational for the removal of MHS ability daily progress note and considered it an importance piece of medical record documentation to accurately reflect the patient's daily behavior and participation.

During an interview on 8/12/24 at 4:25 PM, LN #2 stated MHS documentation stopped occurring in November or December 2023. MHS interactions with patients were no longer being documented in the medical record.

During an interview on 8/12/24 at 5:45 PM, LN #7 stated MHS documentation had been taken away. MHS only now could document on the "Acute Patient Observation Record/Milieu Groups" Every-15-minute (Q15) form (monitoring sheets that accompany staff working with patients; staff are to physically locate and identify the patient's behavior, location, and position every 15 minutes of the day, 24 hours a day). There was nowhere for MHS to document de-escalation with patients or anything else they did with the patients.

During an interview on 8/14/24 at 10:15 AM, the Assistant Chief Nursing Officer (ACNO) stated MHS stopped documenting "notes a longtime ago," and sometime in 2022 documenting was taking away and the MHS was only documenting on the "Acute Patient Observation Record/Milieu Groups" Q15 form. The ACNO further stated he/she identified there was a gap in documentation with the missing MHS notes.

During an interview on 8/19/24 at 12:15 PM, MHS #3 stated MHS did not document in the medical record. MHS documentation was completed on the "Acute Patient Observation Record/Milieu Groups" Q15 form. MHS only documents every 15-minute checks and group/activity participation.

Review of the facility's policy "Medical Record Documentation," dated 1/2022, revealed: ". . . E. The medical record is a legal document: thus, it includes facts, no speculation. Entries are to describe patient behavior, interventions utilized, response to interventions, and plan . . ."
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Based on record review and interview, the facility failed to ensure medical records were complete and legible for 8 patients (#'s 10, 12, 13, 14, 16, 19, 22, and 24,) out of 26 sampled records reviewed. Specifically, the facility failed to ensure:

1) Patient forms in the medical record were original, and instead were photocopies of repeated photocopies, rendering the forms illegible;

2) medical records were complete; and

3) Proper discharge instructions counseling was documented as being completed.

These failed practices placed the patient at risk for: 1) incomplete and illegible medical records, which could affect their ability to obtain continuity of care in the future; and 2) failure at a lower level of care and an increase opportunity for readmission.

Findings:

Patient #10

Record review on 8/13/24 at 8:23 AM, revealed Patient #10 was admitted on 7/2/24 for major depressive disorder, recurrent.

The initial admission consent and acknowledgement form, revised 5/2017, was not an original form, but a photocopied form, which made the words of the form illegible.

Patient #12

Record review on 8/13/24 at 2:15 PM, revealed Patient #12 was admitted on 7/31/24 for major depressive disorder, recurrent.

Further review revealed Patient #12's "Daily Nurse Progress Note," dated 8/12/24, was not an original form, but a photocopied form, which made the words and shaded areas of the form illegible.

Patient #13

Record review on 8/12/24 at 2:20 PM, revealed Patient #13 was admitted 2/10/24 through 5/12/24 for diagnosis major depressive disorder recurrent, severe, with psychosis.

Further review revealed Patient #13 "Daily Nurse Progress Note" forms, dated 2/14/24, 2/18-24/24, 3/24/24, 3/26/-27/24, 3/31-4/1/24, 4/6-9/24, 4/29/24, were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible.

Patient #14

Record review on 8/12/24 at 1:32 PM, revealed Patient #14 was admitted 4/16/24 through 5/15/24 for PTSD and ADHD.

Further review revealed Patient #14's discharge paperwork was illegible and incomplete:

- The "Discharge Plan Part I;" "Aftercare/Discharge Plan Part II;" "Discharge Suicide Risk Reassessment;" "Discharge Safety Plan;" and "Pre-Discharge Evaluation of Risk to Self/Others" forms were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible.

- Patient #14's "Aftercare/Discharge Plan Part II," paperwork's section "Patient Understanding Discharge Plan" was not completed. The following areas were left unchecked on the paperwork: "Patient/Family able to verbalize discharge instructions;" "Patient/Family verbalizes understanding of when/how to seek further treatment;" and "Educational materials provided to patient." Further review revealed it was also not signed by a social worker/therapist or staff member.

Patient #16

Record review on 8/12/24 at 12:20 PM, revealed Patient #16 was admitted 6/1/24 through 8/2/24 for major depressive disorder, single episode, severe with psychotic features.

Further review revealed Patient #16's "Daily Nurse Progress Note" forms dated 6/25-26/24, 7/2-5/24, 7/9-10/24, 7/16-17/24, 7/23-25/24, and 7/30-31/24, were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible.

Patient #19

Record review on 8/12/24 at 11:43 AM, revealed Patient #19 was admitted 6/24/24 through 7/21/24 for opioid dependence.

Further review revealed Patient #19's "Daily Nurse Progress Note," dated 7/18/24, was not completed:

The nurse note's section "2300-0700 Sleep/Behaviors Note" was not completed and the nurse signature, date, and time was missing, and the note's section "Pain [assessment]- 1900-0700" was not completed.

Patient #22

Record review on 8/9/24 at 1:40 PM, revealed Patient #22 was admitted 6/14/24 through 6/30/24 for intermittent explosive disorder.

Further review revealed Patient #22's discharge paperwork was illegible and incomplete:

- The "Aftercare/Discharge Plan Part II;" "Discharge Suicide Risk Reassessment;" "Discharge Safety Plan;" and "Pre-Discharge Evaluation of Risk to Self/Others" forms were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible.

- Patient #22's "Aftercare/Discharge Plan Part II" paperwork's section "Patient Understanding Discharge Plan" was not completed. The following areas were left unchecked on the paperwork: "Patient/Family able to verbalize discharge instructions;" "Patient/Family verbalizes understanding of when/how to seek further treatment;" and "Educational materials provided to patient."

Further review of Patient #22's "Aftercare/Discharge Plan Part II", revealed the section "Nurse to Complete: Condition on Discharge" was missing from the form and medical record.

Patient #24

Record review on 8/9/24 at 1:29 PM, revealed Patient #24 was admitted 6/20/24 through 6/26/24 for post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD).

Further review revealed Patient #24's discharge paperwork was illegible and incomplete:

- The "Discharge Plan Part I;" "Aftercare/Discharge Plan Part II;" "Discharge Suicide Risk Reassessment;" and "Pre-Discharge Evaluation of Risk to Self/Others" forms were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible.

- Patient #24's "Aftercare/Discharge Plan Part II" paperwork's section "Patient Understanding Discharge Plan" was not completed. The following areas were left unchecked on the paperwork: "Patient/Family able to verbalize discharge instructions;" "Patient/Family verbalizes understanding of when/how to seek further treatment;" and "Educational materials provided to patient."

Further review revealed Patient #24's "Aftercare/Discharge Plan, Part II", revealed the section "Nurse to Complete: Condition on Discharge" was missing from the form and medical record.

Review of the facility's original "Aftercare/Discharge Plan Part II" form, revealed a section titled, "Nurse to Complete: Condition on Discharge." If any answers of "yes" to the questions, required a physician to review.

Questions reviewed during the assessment:

- "Does the patient/resident or others report:"
- "The patient/resident reporting suicide ideation/threats? Yes/No;"
- "The patient/resident reporting homicidal ideation/threats? Yes/No;"
- "The patient/resident reporting self-injurious ideation/behavior? Yes/No;"
- "The patient/resident reporting symptoms of psychosis? Yes/No;" and
- "The patient/resident's mood is inappropriate for the situation? Yes/No."

During interview on 8/13/24 at 12:50 PM, Licensed Nurse (LN) #4 reviewed the blank admission paperwork, in an empty chart that was set up for a new admission, and stated some forms were difficult to read. This blank packet of admission paperwork contained photocopied forms. LN #4 acknowledged the forms were placed in empty charts to prepare for admissions. LN #4 stated prepared charts come from the medical records department. He/she stated sometimes completed admission paperwork was received via fax or email making the forms more distorted.

During an interview on 8/13/24at 2:29 PM, the Director of Health Information Management (HIM - Medical Records Director) stated the medical records staff prepped all new medical record charts for potential admissions by placing blank paperwork forms, including discharge paperwork, into the charts for the LNs to use. When asked to review the blank, photocopied forms in active and closed records, as well as new charts prepped for use, the Director of HIM acknowledged the photocopied forms were illegible and shouldn't have been used.

During an interview on 8/14/24 at 11:52 AM, the Director of Quality stated if the discharge instruction box on the discharge paperwork was not checked, no discharge instructions were available.

During an interview on 8/14/24 at 12:10 PM, Clinical Manager (CM) #1 stated the "Aftercare/Discharge Plan Part II" form' section "Nurse to Complete: Condition on Discharge" was removed by the facility's corporate office. CM #1 was unable to recall when the section was removed. CM#1 stated all areas of the discharge paperwork should be completed.

During an interview on 8/14/24 at 12:29 PM, the Quality Director stated that the "Nurse to Complete: Condition on Discharge" LN assessment on the "Aftercare/Discharge Plan Part II" form was removed sometime within the last two years. The Quality Director stated the LNs of the facility had requested it be reinstated and was subsequently put back on recently.

The Quality Director acknowledged the inconsistency identified between the adult discharge packet and the children, preteen, and adolescent discharge packet regarding the "Nurse to Complete: Condition on Discharge" assessment's presence and acknowledged the inconsistency of the "Nurse to Complete: Condition on Discharge" assessment being consistently completed at discharge.

The Quality Director further stated the "Condition on Discharge" LN assessment should be on the Aftercare/Discharge Plan Part II document and it should be on every unit for the LNs to complete for every discharge in the facility.

Review of the facility policy "Discharge/Aftercare Planning, PC128", last revised 12/2023 revealed: ". . . 2. The Discharge Plan should: A. Prepare the patient/resident and family for transition to the next level of care. B. Address the patient'/resident's and family's need for instruction about continued treatment. C. Delineate how progress made in the current level of care will continue after discharge. D. Identify problems to be addressed in the next level of care. E. Identify the responsibility for ensuring that the prescribed follow-up is accomplished. F. Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care. . . 3. . . The discharge plan should take into account the continuation or completion of those treatments that were generated in the current level of care and the initiation of those treatments that are needed but were deferred to another phase of treatment . . . 5. The discharge/aftercare plan should define the following: A. Final diagnosis; B. Where the patient/resident will live following discharge; C. With whom the patient/resident will live and in what circumstances; D. the level of care that the patient/resident will be discharge to. . . E. A listing of all medications that patient/resident is to continue taking after discharge; F. All professionals who will follow-up with the patient/resident, including medical follow-up to monitor medications; G. Referrals. . . H. Specific efforts to educate the family regarding the patient's/resident's treatment interventions, medication, and prognosis; I. Follow up appointments . . . J. Condition on discharge; L. Identified problems and the outcome of those problems; and M. Safety plan. . . 6. Aftercare plans are communicated to the patient/resident and family, as appropriate, and documented in the medical record. Additionally, will be provided to the Guardian at discharge. . . "

Review of the facility policy "Medical Record Documentation," dated 1/2022, revealed: ". . . each entry is to be dated and timed . . . medical record is a legal document . . . Empty spaces are not left in documentation. . . entries are to be written legibly . . ."
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Based on interview and record review, the facility failed to ensure medical records were completed and accurate to reflect patients' progress and response to treatment. Specifically, the facility failed to ensure Mental Health Specialists (MHSs - direct patient care staff working daily with patients within the program environment) had access to document in the medical record to ensure assigned responsibilities from the individualized patient treatment care plans were completed for 5 patients (#'s, 2, 4, 13, 14, and 19), out of 5 sampled patients reviewed for treatment plan implementation. This failed practice placed all patients (based on a census of 63) at risk for not having documentation of daily witnessed interactions and behaviors, as well as interventions received by MHS staff in their medical records, which had the potential to limit appropriate services and/or treatments needed to address their medical, psychological, and psychosocial needs.

Findings:

During an interview on 8/8/29 at 4:04 PM, Licensed Nurse (LN) #10 stated MHS no longer complete daily progress note charting. LN #10 was unsure of the rational for the removal of MHS ability daily progress note and considered it an importance piece of medical record documentation to accurately reflect the patient's daily behavior and participation.

During an interview on 8/12/24 at 4:25 PM, LN #2 stated MHS documentation stopped occurring in November or December 2023. MHS interactions with patients were no longer being documented in the medical record.

During an interview on 8/12/24 at 5:45 PM, LN #7 stated MHS documentation had been taken away. MHS only now could document on the "Acute Patient Observation Record/Milieu Groups" Every-15-minute (Q15) form (monitoring sheets that accompany staff working with patients; staff are to physically locate and identify the patient's behavior, location, and position every 15 minutes of the day, 24 hours a day). There was nowhere for MHS to document de-escalation with patients or anything else they did with the patients.

During an interview on 8/14/24 at 10:15 AM, the Assistant Chief Nursing Officer (ACNO) stated MHS stopped documenting "notes a longtime ago," and sometime in 2022 documenting was taking away and the MHS was only documenting on the "Acute Patient Observation Record/Milieu Groups" Q15 form. The ACNO further stated he/she identified there was a gap in documentation with the missing MHS notes.

During an interview on 8/19/24 at 11:39 PM, Clinical Therapist (CT) #15 agreed that MHS were assigned interventions in the individualized treatment plans of patients. When asked how the MHS documented about those interventions assigned, CT #15 couldn't explain how since they were no longer charting in the medical record.

During an interview on 8/19/24 at 12:15 PM, MHS #3 stated MHS did not document in the medical record. MHS documentation was completed on the "Acute Patient Observation Record/Milieu Groups" Q15 form. MHS only documents every 15-minute checks and group/activity participation.

During an interview on 8/19/24 at 12:15 PM, Milieu Manager #1 stated MHS did not directly document in the medical record. When asked how MHS would document interventions assigned to them in the individualize treatment plans for patients, like encourage use of coping skills, Milieu Manager stated those interventions would not be documented in the medical record and agreed it created the inability to properly document all interventions provided.

Record review on 8/15/24 at 8:24 AM, of patient "Acute Master Interdisciplinary Treatment Plans", which included staff responsibilities, patient activities, goals, and target dates, revealed interventions in patient goals that were to be conducted by MHS staff:

Patient #2

Patient #2 was admitted on 6/13/24 for alcohol dependence.

Further review revealed Patient #2's treatment plans, dated 6/14/24, 6/20/24, 6/27/24, 7/5/24, 7/11/24, 7/18/24, 7/25/24, 8/8/24, and 8/13/24, identified:

"Short-Term Goals/Objectives": Each time I have the urge/thought to use alcohol I will use a safe distraction to eliminate/reduce substance consumption and share with staff each shift and with CT during IT sessions for 7 days."

"Staff Interventions": "During daily CD/psychoeducation group, MHS staff will provide psychoeducation about substance abuse and AA step work in order to increase self-awareness and reduce severity of urges. Daily, MHS staff will process homework assignments for AA step work in order to increase understanding of AA principles."

Patient #4

Patient #4 was admitted on 7/22/24 for alcohol dependence.

Further review revealed Patient #4's treatment plans, dated 7/25/24, 7/31/24, 8/7/24, 8/14/24, identified:

"Short-Term Goals/Objectives": Each time I have the urge/thought to use alcohol I will use a safe distraction to eliminate/reduce substance consumption and share with staff each shift and with CT during IT sessions for 7 days."

"Staff Interventions": "During daily CD/psychoeducation group, MHS staff will provide psychoeducation about substance abuse and AA step work in order to increase self-awareness and reduce severity of urges. Daily, MHS staff will process homework assignments for AA step work in order to increase understanding of AA principles."

Patient #13

Patient #13 was admitted 2/10/24 through 5/12/24 for major depressive disorder recurrent severe with psychosis.

Further review revealed Patient #13's treatment plans, dated 2/14/24, 2/21/24, 2/28/24, 3/6/24, 3/13/24, 3/20/24, 3/27/24, 4/3/24, 4/10/24, 4/17/24, 4/24/24, 4/29/24, and 5/7/24, identified:

"Short-Term Goals/Objectives": Each time I have the urge to hurt myself or thoughts of committing suicide, I will journal, or take a walk and/or talk with someone I trust, without acting upon the urge, share my thoughts with staff each shift and weekly with my CT during IT and FT for 1 week.

"Staff Interventions": "MHS [#3] will closely monitor for signs, suicidal ideation, aggression, and emotional dysregulation that includes depressed mood and feelings of anxiety. Staff will encourage youth to use coping skills (i.e., coloring, listening to music, talking to staff) as well as notify the nurse of any concerns."

Additional treatment plans, dated, 4/26/24 and 5/7/24, included:

"Short-Term Goals/Objectives": Each time I have the urge/behavior/or hear voices that tell me to hurt or kill myself or others, I will ask for a walk or talk to staff without acting on the urge/thought and use a safe distraction or distress tolerance skill from my Special program and then return to regular scheduled programming for 7 days. I will share with staff each shift and with my CT weekly during IT/FT."

"Staff Interventions": "MHS [#3] will closely monitor for signs and symptoms of depression, isolation, self-harm, or responding to internal stimuli & encourage the patient to take a time out for five minutes and utilizing a distraction or distress tolerance coping skill as well as notify the nurse or MD of any concerns."

Patient #14

Patient #14 was admitted on 6/26/24 for attention deficit hyperactivity disorder (ADHD) and Post-Traumatic Stress Disorder (PTSD).

Further review revealed Patient #14's treatment plans, dated 6/28/24, 7/3/24, 7/10/24, 7/17/24, 7/24/24, 7/31/24, and 8/7/24, identified:

1. "Short-Term Goals/Objectives": Each time I feel angry, I will ask for a 5-minute break and write things out or discuss with staff each shift and with my CT weekly during IT and FT sessions for 1 week."

"Staff Interventions": MHS [#3] will closely monitor for signs, suicidal ideation, aggression, and emotional dysregulation that includes depressed mood and feelings of anxiety. Staff will encourage youth to use coping skills (i.e., coloring, listening to music, talking to staff) as well as notify the nurse of any concerns.

2. "Short-Term Goals/Objectives": "When I feel like I am being bullied, I will walk away from the situation and immediately report to staff without engaging in arguments or hitting my peers. I will use a skill from my BMP to manage my mood, 3 out of 4 times. I will share my success and challenge with staff daily and CT in IT/FT for 1 week."

"Staff Interventions": MHS [#3] will closely monitor for signs and symptoms of depression, isolation, self-harm, or responding to internal stimuli & encourage the patient to take a time out for five minutes and utilizing a distraction or distress tolerance coping skill as well as notify the nurse or MD of any concerns."

3. "Short-Term Goals/Objectives": Each time I have the urge to hurt myself or thoughts of committing suicide, I will stop the thought, and distract myself by asking to take a walk, without acting upon the urge, share my thoughts with staff each sift and weekly with my CT during IT and FT for 1 week."

"Staff Interventions": MHS [#3] will closely monitor for signs Suicidal Ideation, Aggression, and emotional Dysregulation that includes depressed mood and feelings of anxiety. Staff will encourage youth to use coping skills (i.e., Writing, Walking, Talking to Staff" as well as notify the nurse of any concerns."

Patient #19

Patient #19 was admitted 6/24/24 through 7/21/24 for opioid dependence.

Further review revealed Patient #19's treatment plans, dated 6/26/24, 7/3/24, 7/10/24, and 7/16/24, identified:

"Short-Term Goals/Objectives": "Each time I have the urge/thought to use fentanyl I will use a safe distraction to eliminate/reduce substance consumption and share with staff each shift and with CT during IT session for 7 days."

"Staff Interventions": "Daily CD/psychoeducation group, MHS staff will provide psychoeducation about substance abuse and AA Step work in order to increase self-awareness and reduce severity of urges. Daily, MHS staff will process homework assignments from AA step work in order to increase understanding of AA principles."


Review of the facility's policy "Medical Record Documentation," dated 1/2022, revealed: ". . . E. The medical record is a legal document: thus, it includes facts, no speculation. Entries are to describe patient behavior, interventions utilized, response to interventions, and plan . . ."

Review of the facility's policy "Interdisciplinary Patient-Centered Care Planning- Acute," dated 7/2023, revealed: ". . . Each discipline completing their individual assessments will begin to identify the patient's problems to be treated and the focus on their treatment interventions which will be included in the MTP [Master Treatment Plan] . . . Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention. . ."
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Based on record review and interview, the facility failed to ensure a brief summary of the patient's condition on discharge was documented for 4 Patients (#'s 14, 22, 23, and 28), out of 13 closed patient records reviewed. Without an accurate assessment of the patient's immediate status at discharge, to include psychiatric, physical, and functional conditions, these patient were risk for complications after discharge.

Findings:

Discharge Paperwork Review

Adult Programs

Review of the discharge paperwork for the Arctic Recovery Program and the Chris Kyle Patriot Hospital revealed the following paperwork was included in the "discharge packet":

1. Pre-Discharge Checklist
2. Discharge Assessment Plan for Nursing Department

This assessment included a checklist that included answering "yes" or "no" if vital signs were completed (but not documented on the form), ensuring all patient belongings were accounted for, the patient's room has been cleared, all facility property was returned, and all copies and prescriptions were collected and provided to the patient. Also, medication reconciliation (ensuring all medication brought in on admission were returned) and medication education was completed. The patient's diagnosis was discussed, and any answers were discussed, answered any concerns the patient had about discharge, and identifying any escort associated with the discharge. There was also a section to complete if a patient was leaving against medical advice (AMA). Signature lines were provided for the patient, escort, and nurse to sign, date, and time the form.

3. Pre-discharge evaluation of risk to self/others.

This form assessed any suicidal or homicidal thoughts and any risk management considerations to discharge. The Provider completed this form and if it was a sudden or immediate discharge, there was a place for the nurse to conduct a verbal review with the Provider if they were not available.

4. Discharge Suicide Risk Reassessment

This form was a reassessment, once treatment has been completed, to ascertain if there were any immediate risks for suicide and any actions taken based on that risk. The Clinical Therapist and Provider would sign this form.

5. Discharge Safety Plan

This form reviewed potential trigger, warning signs, and coping strategies, and how to make a safe environment for after discharge.

6. Discharge Plan Part I

This was the Providers documentation of discharge to include reason for admission, medical procedures performed during admission, medical follow-ups if needed, tobacco cessation medication at discharge if applicable, and discharge diagnosis and medication supplied.

7. Aftercare/Discharge Plan Part II

This form had different sections for the Clinical Therapist and Licensed Nurse (LN) to completed.
- The Clinical Therapist completed the sections "Follow-up appointments;" "Other Aftercare Services/Referrals;" "Family Involvement;" and "Patient Understanding of Discharge Plan."
- The LN completed the date of admission and discharge, what type of discharge it was (scheduled, AMA, at family's request, or other).

On page two of the paper was a "Condition on Discharge" assessment the LN completed which reviewed and suicidal or homicidal thoughts, and self-injurious thoughts, and ruled out any psychosis or inappropriate mood concerns. A set of vital signs were documented, and the LN signed this assessment. There was also a check list to ensure appropriate copies were provide to the patient.

8. There were also papers that reflected lab values, what behaviors were observed during the admission, discharge medication instructions, and health-related needs.

Children, Preteen, and Adolescent Programs

Review of the discharge paperwork for the inpatient program for minors revealed the following paperwork was included in the "discharge packet":

1. Pre-Discharge Checklist
2. A discharge cover letter
3. Pre-discharge evaluation of risk to self/others.
4. Discharge Suicide Risk Reassessment
5. Discharge Safety Plan
6. Discharge Plan Part I
7. Aftercare/Discharge Plan Part II

The Children, Preteen, and Adolescent's After/care Discharge Plan Part II was missing the LN "Condition of Discharge" assessment that should have been on page two of the paper.

8. There were also papers that reflected lab values, what behaviors were observed during the admission, discharge medication instructions, and health-related needs.
Medical Record Review

Children, Preteen, Adolescent Closed Records

Patient #14

Record review on 8/12/24 revealed Patient #14 was admitted to the facility on 4/16/24 and discharged on 5/15/24 at 5:00 PM. Further review revealed the following deficiencies:

- Pre-discharge evaluation of risk to self/others: Was completed on 5/14/24 at 1:00 PM.
- Discharge Suicide Risk Reassessment: was completed on 5/13/25 at 4:30 PM.
- Discharge Safety Plan: This was completed 5/13/24 at 7:30 AM.
- Discharge Plan Part I: Was completed on 5/15/24 however the time of completion could not be legibly interpretated.
- Aftercare/Discharge Plan Part II: Was completed, but not signed, dated, or times by the Clinical Therapist who completed the paperwork. It could not be determined when this piece of the discharge paperwork was completed.

There was no "condition on discharge" assessment on the paper.

Further review of the discharge paperwork revealed no condition on discharge assessment at the time of discharge, 5/15/24 at 5:00 PM.

Patient #22

Record review on 8/9/24 revealed Patient #22 was admitted to the facility on 6/14/24 and discharged on 7/11/24 at 7:00 PM. Further review revealed the following deficiencies:

- Pre-discharge evaluation of risk to self/others: Was completed on 7/11/24 at 5:00 PM.
- Discharge Suicide Risk Reassessment: was completed on 7/10/24 at 4:00 PM.
- Discharge Safety Plan: This was completed 7/10/24 at 4:00 PM.
- Discharge Plan Part I: Was completed on 7/11/24 however the time of completion could not be legibly interpretated.
- Aftercare/Discharge Plan Part II: Was completed by the Clinical Therapist on 7/10/24 at 4:00 PM. There was no LN "condition on discharge" assessment on the paper.

Further review of the discharge paperwork revealed no condition on discharge assessment at the time of discharge, 7/11/24 at 7:00 PM.

Adult Closed Records

Patient #23

Record review on 8/12/24 revealed Patient #23 was admitted to the facility on 7/22/24 and discharged on 7/22/24 at 3:15 PM. Further review revealed the Aftercare/Discharge Plan Part II paperwork was incomplete. The "Condition of Discharge" LN section was left blank.

Patient #28

Record review on 8/19/24 revealed Patient #28 was admitted to the facility on 8/3/24 and discharged on 8/17/24 at 5:00 PM. Further review revealed the Aftercare/Discharge Plan Part II paperwork was incomplete. The "Condition of Discharge" LN section was left blank.

During an interview on 8/14/24 at 12:29 PM, the Quality Director stated that the "Condition on Discharge" LN assessment on the Aftercare/Discharge Plan Part II document was removed sometime within the last two years. The Quality Director stated the LNs of the facility had requested it be reinstated and was subsequently put back on recently.

The Quality Director acknowledged the inconsistency identified between the adult discharge packet and the children, preteen, and adolescent discharge packet regarding the "Condition on Discharge" assessment's presence and acknowledged the inconsistency on getting the "Condition on Discharge" assessment completed at discharge.

The Quality Director stated the "Condition on Discharge" LN assessment should be on the Aftercare/Discharge Plan Part II document and it should be on every unit for the LNs to complete for every discharge in the facility.

Review of the facility's policy "Discharge/Aftercare Planning," effective 12/2023, revealed: ". . . The discharge/aftercare plan should define the following . . . condition on discharge . . ."
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