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Based on record review, policy review, observation and interview, it was determined that the facility failed to ensure 1 of 1 patient (#20) was free from abuse and neglect, Patient (#20) had attempted suicide twice while hospitalized and was never reassessed. Patient #20 also was given chemical and physical restraints even though there was no indication at the time to warrant the restraints. The facility also failed to ensure staff followed policies and procedures while applying restraints and obtain orders for physician orders for physical restraints in # of # patients. The cumulative effect of these systemic problems resulted in the facilities inability to provide quality care in a safe environment resulting in the Condition of Patient ' s Right not met.

Findings include:

1. Ensure that patients were free of all forms of abuse and neglect which resulted in injury and failed to ensure that staff promote and protect patient rights by reassessing patients with suicidal ideation in 1 of 1 patient (#20). This resulted in an immediate jeopardy. See (A-145 and 154)

3. Ensure that staff follow policies for physical restraint and seclusion of patients. See(A-154)

4. Ensure that staff apply physical restraint according to hospital policies and procedures. See (A-167)

5. Ensure that staff obtain a physician's order for physical restraint of patients. See (A-168)

Based on observation, interview and record review, the facility failed to ensure that 1 of 1 current patients (#20) was free of neglect and physical injury related to the facility's failure to:
1. assess the patient's suicidal statements and attempts at self-harm and follow-up per policy
2. monitor staff handling of patients during restraint and physical management to ensure compliance with facility training and avoid patient injury.
3. thoroughly investigate the patient's complaint of staff abuse.
Findings include:

Suicide Risk Record Review:
On 7/23/12 from 1200-1700 hours, review of patient #20's clinical record revealed that he remained on General Suicide Precautions (GSP), with 15 minute checks, from 7/11/12-7/23/12. Review of the documentation noted the patient's level of supervision was not changed after the patient made statements of self harm and attempts to injure self had manifested.

I. Suicidal statements ignored: On 7/12/12 at 1120 hours the Recreation Therapist documented the following in patient #20's record: "This writer reported (Pt. #20) suicidal thoughts and verbally stating suicidal thoughts to Dr. (Psychiatrist #1) Social Worker (SW #2) and Charge Nurse (B Unit)." No updated suicide assessment or contact with the patient's physician to inform him of the above was noted in the clinical record.

Suicidal statement ignored: On 7/17/12 at 1150 hours, Psychiatrist #1's progress note states that patient #20 was, "not compliant...remains unpredictable...threatening to kill himself." There was no documentation of suicidality reassessment or consideration of increased supervision noted in the record.

Policy:
"Active Suicide (AS) and General Suicide Precautions (GSP)," dated 3/11/11 states: "The decision for any patient being placed on precaution is primarily the responsibility of the attending psychiatrists. While nursing staff may initiate such precaution, the decision has to be ratified by the attending psychiatrist."

Interview:
On 7/24/12 from 1110-1120 hours, Psychiatrist #1 was asked whether he documented a suicide assessment of supervision needs for patient #20 after writing his 7/17/12 note, or of being informed of the patient's suicidal statements on 7/12/12. He stated that he did not.

2. Self-harm attempts ignored: On 7/17/12 at 1230 hours, a nursing progress note states that patient #20, "took eating fork and attempted to cut wrist with fork." There was no documentation of suicide risk being assessed or completion of an Incident Report.

Policies:
"Incident Reports," dated 3/21/11:
(1) "Incident Reports will be completed whenever an unexpected occurrence happens to a patient..."
(4) "In urgent situations (...suicide attempts...) the Incident Report will be reported immediately to the Director of Nursing or Medical Director."

"Active Suicide and General Suicide Precautions," dated 3/11/11 states:
"It is the policy of (facility name) to initiate reasonable precautionary measures and to provide special care for patients who are likely to harm themselves or take their own life."
"The decision for any patient being placed on precaution is primarily the responsibility of the attending psychiatrist. While nursing staff may initiate such precaution, the decision has to be ratified by the attending psychiatrist."
Procedures: Registered Nurse: "Within 1 hour informs Physician of Patient's change in status."

Interview:
On 7/24/12 from 1110-1120 hours Psychiatrist #1 was asked if he was aware of this incident or had documented anything regarding the patient's suicide risk or supervision needs following the above incident of self-injury. Psychiatrist #1 stated that he had not done so.

Self harm attempt ignored: On 7/18/12 at 0930 hours a nursing progress note for patient #20 states: "...attempted to choke himself with sheet-staff removed all linens from room." On 7/18/12 patient #20 was physically restrained from 0930-1200 hours. An addendum to a nursing note written at 1230 hours states that patient #20 stated: "I'm going to kill myself." There was no suicide reassessment or documentation of asking the physician to assess supervision needs for safety.

Policies:
"Incident Reports," dated 3/21/11: "(4) In urgent situations (...suicide attempts...the Incident Report will be reported immediately to the Director of Nursing or Medical Director."
"Active Suicide and General Suicide Precautions," dated 3/11/11 states:
"It is the policy of (facility name) to initiate reasonable precautionary measures and to provide special care for patients who are likely to harm themselves or take their own life."
"The decision for any patient being placed on precaution is primarily the responsibility of the attending psychiatrist. While nursing staff may initiate such precaution, the decision has to be ratified by the attending psychiatrist."
Procedures: Registered Nurse: "Within 1 hour informs Physician of Patient's change in status."

Interviews:
On 7/24/12 from 1110-1120 hours Psychiatrist #1 was asked whether he was aware of the patient's attempt to choke himself with linens on 7/18/12. He stated that he was not made aware of this incident.

On 7/24/12 at approximately 1555 hours the Nurse Manager and Director of Nursing were asked if they were aware of the patient's choking incident on 7/18/12. Both stated that they were not made aware of the incident. Both nurses verified that there was no Incident Report completed relative to this incident and that one should have been done.

3. Patient allegation of injury by staff related to improper physical restraint application: Record and Video Review:
Patient injury documentation: On 7/23/12 at 1055 hours the Recipient Rights Advisor (RRA) reviewed documentation of an allegation of staff abuse by patient #20. The RRA received the complaint on 7/19/12. Pictures taken that day show elongated bruises, consistent with finger marks, on the patient's right upper extremity. These marks were still visible in the same positions on 7/23/12. The clinical record indicated that the patient was physically restrained on 7/17/12 and 7/18/12. These findings were verified by the RRA.

Video observation of improper restraint: On 7/24/12 at approximately 1230 hours review of video tapes dated 7/18/12 from 0930-0945 hours, showed 3 staff carrying patient #20 from his room down the corridor to the seclusion room. One staff member held both of the patient's feet. One staff member held the right wrist and another held the patient's left wrist. Patient #20 hung between staff, with his back inches above the floor. The patient's head and trunk were unsupported. These observation was verified by the Security Manager. .

Policy:
There is nothing in the facility's Restraints policy or their CPI (Nonviolent Crisis Intervention) manual describing the technique observed on the video tape for carrying a patient or clarifying why patient #20 sustained finger mark patterned bruises on his right upper extremity.

Interview::
On 7/24/12 at 1600 hours the Director of Nursing verified that staff are required to use Crisis Prevention Institute (CPI) techniques in physically managing and restraining patients and that these protocols do not allow for the type of patient carry observed on the video or result in bruising to the upper extremities. During a review of the CPI training manual with the Director of Nursing, she confirmed at this time that patient #20 was not carried by staff in a manner that is approved or trained to staff through CPI training.

4. Facility failure to identify patient abuse investigation protocol: Record Review and Interviews:

On 7/23/12 at approximately 1030 hours the Recipient Rights Advisor (RRA) and Surveyor met with patient #20. Patient #20 had filed a complaint with the Recipient Rights Advisor, received 7/19/12, alleging that a staff member hit him in the face. The RRA stated that she was unable to identify a likely match among the staff in regard to the allegation of hitting the patient and no bruising on the patient's face was noted. However, the survey interview did note the patient had bruises on his right upper arm. The RRA was asked if she reported the patient's abuse allegation to facility administration or nursing staff. The RRA stated that she reported it to the Nurse Manager but was not sure if further investigation was done.

On 7/24/12 at approximately 1415 hours during another survey interview the Director of Nursing and Nurse Manager were asked to state the facility's role in investigating patient allegations of staff abuse. Neither was able to articulate facility policies or procedures beyond stating that the RRA conducts an investigation. The Nurse Manager stated that he was aware of patient #20's allegation of abuse by staff but had not documented any investigation or other actions in response to the allegation and was not sure what role nursing has in abuse investigations.

Based on observation, interview and record review, the facility failed to ensure that 1 of 1 current patients (#20) was free from chemical restraint. Findings include:

Current Patient: Chemical restraint without indication for use:

1. A progress noted dated 7/17/12 at 2415 hours (sic), a nursing progress note stated, "Patient at desk yelling at nurse calling her bitch and other expletives...Hit top of the desk several times. Very loud and agitated. Received order for physical hold along with PRN."(sic).

2. Review of video footage on 7/17/12 from 2300-0100 hours revealed that patient #20 stood at the nursing station desk and pounded on the counter top at approximately 0002 hours. He appeared to be yelling. After a few minutes he left the desk and proceeded to the far end of the corridor and sat down. No other episodes of this description were noted on the video that night. (The 0002 video clip corresponds with details in the facility's 2415 [sic] progress note.)

3. Review of the facility's video on 7/17/12, from the time of the observation of the patient's fist pounding behavior at 0002 hours until 0030 hours, patient #20 was seated calmly in a window seat at the end of a corridor furthermost from the nurses's station. At 0034 hours, 5 staff, including 1 nurse, approached the calm patient and walked him to his room, no repeats of acting out behavior were noted. The fist pounding episode was described in the nursing progress note as the reason for giving patient #20 PRN psychotropic medications.


4. The Medication Administration Record (MAR) notes that 1 ml of Haloperidol and 2 mg. of Ativan IM (injections) were given to patient #20 on 7/17/12 for, "severe agitation." It was documented as given at 2400 hours. A review of the video survellance tape showed a time stamp of 0034 for the time of the injection.

Facility policy titled, "Restraints," revised 6/11, states: "Chemical/drug restraint is defined as using medication for control of behavior for restrained patient freedom of movement and there is not a standard treatment for the patient's medication or psychiatric condition."

The above findings were verified with the Director of Nursing (DON) during an interview on 7/24/12 at approximately 1600 hours.

Based on observation, interview and record review, the facility failed to follow policies for restraining 1 of 1 current patients (#20) placing him at risk for physical injury. Findings include:

Policy:
The facility's "Restraints," policy, revised 6/11, states:
"G. Personnel who may be required to implement restraint, as well as the entire treatment team, shall receive documented training annually...."

On 7/25/12 at approximately 0930 hours, the facility's Human Resources Manager was asked to provide documentation of annual training in the application of restraints for a sample of 6 nursing staff members (Staff identifier's; (C, F, P, Y, Z & AA). All 6 had current Crisis Prevention Institute (CPI) training cards on file. The HR Manager stated that CPI training is required at hire and prior to card expiration.

Record Review:
1. On 7/23/12 at 1055 hours the Recipient Rights Advisor (RRA) reviewed documentation of an allegation of staff abuse by patient #20. The RRA received the complaint on 7/19/12. Pictures taken that day show elongated bruises, consistent with finger marks, on the patient's right upper extremity. These marks were still visible in the same positions during the survey on 7/23/12. Patient #20 was physically restrained on 7/17/12 and 7/18/12. These observations were verified by the Recipient Rights Advisor.

2. On 7/24/12 at approximately 1230 hours review of video tapes dated 7/18/12 from 0930-0945 hours, showed 3 staff carrying patient #20 from his room down the corridor to the seclusion room. One staff member held both of the patient's feet. One staff member held the right wrist and another held the patient's left wrist. Patient #20 hung between staff, with his back inches above the floor. The patient's head and trunk were unsupported. These observation was verified by the Security Manager. .

Policy:
Review of the facility's Restraints policy and their CPI manual noted no policies or protocols describing the technique observed on the video tape or clarifying why the patient sustained finger mark shaped bruises on his right upper extremity.

Interview::
On 7/24/12 at 1600 hours the Director of Nursing verified that staff are required to use CPI (Crisis Prevention Institute.) techniques in physically managing and restraining patients. She also verified that there is nothing in CPI training to explain the bruises on patient #20's upper right arm or the video clip of him being carried down the hallway in the manner described above.

Based on record review and interview, the facility failed to obtain complete physician orders for restraints for 1 of 1 current patients (#20) and for 5 of 9 discharged patients (#13, #14, #19, #29, #30 ) who were physically restrained. Findings include:

Facility policy titled, "Restraint," reviewed 6/11, and identified by the DON (Director of Nursing) as in effect on 7/23/12, states: "1. There must be a written physician's order for each use of physical restraint." and "3. Verbal orders for restraints are documented on the [Physician's Order Form] for the initial physical restraint order." The policy goes on, "All verbal orders must be signed by physician's within 24 hours with signatures, date and time.
11) physician's orders must specify:
1) The maximum length of time restrain is to be used.
2) the reason for the restraint
3) The type of restrain used.
4) ...behaviors (s) which made use of restraint necessary"

On 7/23/12 from 1130-1700 hours, review of patient #20's clinical record revealed the following:

1) a telephone order dated 7/12/12 at 1540 hours for a physical hold with no physician's signature
2) a telephone order dated 7/12/12 at 1540 hours for PRN (as needed) medications for agitation with no signature (chemical restraint).
3) a telephone order dated 7/13/12 at 1145 hours for physical hold with no ordering physician named and no physician's signature.
4) a telephone order dated 7/12/12 at 1750 hours for physical hold with no physician's signature.
5) a verbal order dated 7/17/12 at 1145 hours for 4 point leather restraints with no indication for use, no ordering physician named and no physician's signature.
6) a 7/17/12 order at 2415 hours with no ordering physician named, no method of restraint named and no physician's signature.
7) a telephone order dated 7/18/12 at 0930 hours for 4 point leather restrains with no indication for use, no ordering physician and no signature.

The findings above were verified by the Director of Nursing on 7/24/12 during an interview at approximately 1400 hours.













28273


During review of the medical record for patient #13 on 07/24/2012, it revealed that on 05/30/2012 an order documented as a telephone order was received for the patient to be physically held for administration of medication by a court order. The order was written by the RN at 2100 on 05/30/2012. There was no name on the order identifying the ordering physician . The order was then signed by staff O ( a physician) on 07/07/2012.

Patient #14's medical record revealed that staff received a telephone order for physical hold and seclusion (for up to 4 hours) of the patient due to aggressive behavior on 04/09/2012 at 0930. The nursing staff failed to identify who they had called to receive the telephone order from. The order was then signed by staff O on 07/07/2012.

Review of the medical record for patient #19 on 07/24/2012, revealed a document titled, "Restraint Physician Order Sheet" that contained a telephone order written on 06/29/2012 at 0450 for 4 point restraints up to 4 hours, again lacking identification of who the ordering physician was that the RN contacted for the order.
On 06/29/2012 at 0915 two documents; #1 titled, "Physician Order Sheet", revealed a telephone order was written for the patient to, "Place the patient in seclusion room." The order failed to identify a time frame for the seclusion.
#2 document titled, "Restraint Physician Order Sheet" contained a telephone order that reads, "initiate seclusion protocol for severe agitation/harmful behavior to self & other others." The order lacked a time limit for the seclusion and was not signed by the physician. An order for patient #19 was then written on 06/29/2012 at 1345, stating, "Discontinue 1: 1 and 4 point restraints resume GSP safety precautions. The record lacked documentation of an order to continue restraints after the first order from 0450-0850. The document titled, "Seclusion/Restraint Documentation Form" revealed that on 06/29/2012 at 0953 the patient, who was in the seclusion room demonstrated, "escalating behavior" and staff documented the following, "4 pt restraint order was given and initiated per protocol" for which there was no order documented on the chart.

A review of the medical record for patient #29 on 7/24/12, revealed that on 1/4/12 at 0940 a telephone order was written on the document titled, "Physician Order Sheet" for applying, "4 point restraints for up to four hours for violent, aggressive behavior," The order lacked a physician signature. On 1/4/12 at 1610, a telephone order was written on a document titled, "Restraint Physician Order Sheet" that revealed an order for 3 point leather restraints for hostile and self harm behavior. Under duration (Time Limit) "To St. Johns Hospital" was written. The order lacked the name of the ordering physician and a physician signature

Findings were verified by Staff C during an interview on 7/24/12 at 1545.

Based on document review and interview, the medical staff failed to enforce bylaws. Findings include:

On 7-25-2012 the hospital ' s current medical staff bylaws, dated 4-4-2012, were reviewed.

Medical Staff Bylaws:
N. " The medical record must be completed within 15 days after the chart is available to the physician from the Record Room, not to exceed 30 days after discharge. Notification from the Record Room will be given to attending physician ' s whose discharge records have aged 8 days and remain incomplete. If these records are not completed with 7 days of the notice the attending psychiatrist will temporarily lose all admission privileges. .. "

O. " Any psychiatrist who has remained on the list as having delinquent records for a period of four consecutive weeks will lose all privileges except for present inpatients until the charts are completed. "

On 7-23-2012 at approximately 2:10 pm, Staff G (medical records) generated a report of current deficient/delinquent charts greater than 30 days. The report indicated that there were currently 181 deficient/delinquent charts for 8 separate doctors with discharges dated 2-14-2012 through 6-26-2012. Staff G stated, she sends weekly reports of deficient/delinquent charts to both Staff A (CEO) and Staff B (COO).

On 7-23-2012 at 3:55 pm Staff A was queried as to his process of dealing with doctors with deficient/delinquent charts. Staff A stated, he sends out an e-mail to the doctor(s) stating that admission privileges will be suspended if not corrected within 5 days of receipt of letter. Staff A supplied printouts of e-mail correspondences with Staff S (psychiatrist), e-mail dated June 5, 2012 notification of 57 delinquent records greater than 30 days and e-mail dated July 2, 2012 notification of 77 delinquent records greater than 30 days.

On 7-25-2012 at 10:15 am Staff Q (medical director) was queried regarding the deficient/delinquent records greater than 30 days. Staff Q stated, " I know there have been problems with just a few doctors not getting their charts signed. "

On 7-25-2012 a report was created that listed the admission dates of all Staff S patients for the past 60 days. The most recent admission of a new patient was on 7-9-2012, even though Staff S had deficient/delinquent charts dating back to 2-14-2012.

Based on record review, interview and policy review, the facility failed to ensure that staff maintains a complete, accurate, accessible and legible medical record for all patients served at the facility resulting in the potential for medical errors and patient harm. Findings include:
1. The facility failed to ensure that the medical record system utilized ensures prompt completion of medical records, an organized filing system of the medical records and prompt retrieval of medical records (See A-438).
2. The facility failed to ensure that the medical records are legible, complete, dated and signed by a physician (See A-450)
3. The facility failed to ensure that all orders are dated, timed and signed by a physician (See 454)
4. The facility failed to ensure that verbal orders are signed by a physician per facility policy (See 457)
5. The facility failed to ensure that all medical records contain a discharge summary in accordance with hospital policy (See 468)
6. The facility failed to ensure that medical records are completed within 30 days of the patient ' s discharge (See 469)

Based on observation and interview, the facility failed to maintain a medical record system that ensures prompt completion of the medical records and failed to ensure that the facility has an accessible system for filing and retrieval of medical records resulting in the potential for a delay in treatment and continuity of care. Findings include:

During a review of the medical record department on 07/25/2012 at 1400, it revealed a small room with several boxes sitting on the floor and on shelves. There were also small bookcases/filing cabinets that contained medical records. It was also noted that some of the shelving in the area was starting to buckle under the weight of the records.

During an interview with staff G on 07/25/2012 at 1430, when queried as to what was the process for completion of medical records, she reported that the records are placed in a bookcase type stand or on top of the stand or on the table depending on what doctor they are for. An e-mail is then sent out to the physician and the FA in regards to needing to sign medical record entries. At the time of survey the facility had 181 incomplete medical records greater than 30 days post discharge. When asked about the filing system for the department, staff G stated that "the records are stored in areas according to the month and year that the patient was at the facility." So when asked if a record was needed for the month of January 2012 if they would have to go through boxes to find it staff G replied "yes." When asked if records are always stored in boxes and all over the floor staff G replied "Yes." During the survey process a request was made on 07/25/2012 at 1500 for 10 additional medical records. At 1700, staff G had located 9 of the requested records and stated that she "couldn't find the last record yet" and that she would continue to look for it the next day. On 07/26/2012, staff G was still unable to locate the 10 th record requested.

Based on medical record review and interview the facility failed to ensure all orders are signed by physicians for 5 of 7 charts reviewed ( #16, 17, 18, 19, 29) and that the medical record is legible for 4 of 7 patients ( #16, 17, 18, 19), resulting in the potential for medical errors and poor patient outcomes. Findings include:

During review of the medical record for patient #29 on 07/25/2012 at 1630 , it revealed that a telephone order dated 01/04/2012 at 1610 and a second order dated 01/04/2012 at 1622 both lacked authentication by a physician.

The findings were confirmed by staff B on 07/25/2012 at 1645.



29774

On 7/24/12 from 1300-1530 during medical record review for patient numbers 16, 17, 18 and 19 revealed medical orders, signatures and progress notes that were illegible. This was confirmed by Staff C on 7/24/12 at 1530.

Based on record review and interview the facility failed to ensure that all orders are signed promptly by a physician for 3 of 7 (18,19,29) records reviewed resulting in the potential for medical errors and patient harm. Findings include:

During review of the medical record for patient # 29 on 07/25/2012 at 1600, it revealed that two telephone orders taken on 01/04/2012 had not been signed by a physician.

During an interview with staff B on 07/25/2012 at 1645, the findings were confirmed.


29774

On 7/24/12 during closed medical record review for patient #19 revealed Restraint Physician Order Sheet telephone orders for " 4 point leather restraints " dated 6/29/12 at 0450 whose telephone order was illegible for nurse signature and ordering physician. Another telephone order for 4 WLR restraints was documented on 6/29/12 at 0953 from Dr. Nair by the nurse; however the physician never signed, dated nor timed the telephone order. On 6/29/12 at 0915 on a document titled " Restraint Physician Order Sheet " a nurse took an order that read " initiate seclusion for severe agitation /harmful behaviors to self and others " that was taken by the RN from the physician, however the physician never signed, dated nor timed the order.
On 7/24/12 at 1500, during closed medical record review for patient #18 revealed that a document titled Physician Initial Order sheet contained no checkmarks next to the " Admit To, Laboratory and Diagnostic Studies, Psychological Testing, Additional Orders or Precautions " sections

Based on medical record review and interview the facility failed to ensure that telephone orders are signed by a physician for 2 of 7 ( # 19, 29 ) medical records reviewed resulting in the potential for medical errors and patient harm. Findings include:
During review of the medical record for patient # 29 on 07/25/2012 at 1600, it revealed that two telephone orders taken on 01/04/2012 had not been signed by a physician.


29774

On 7/24/12 during closed medical record review for patient #19 revealed Restraint Physician Order Sheet telephone orders for " 4 point leather restraints " dated 6/29/12 at 0450 whose telephone order was illegible for nurse signature and ordering physician. Another telephone order for 4 WLR restraints was documented on 6/29/12 at 0953 from Dr. Nair by the nurse; however the physician never signed, dated nor timed the telephone order. On 6/29/12 at 0915 on a document titled " Restraint Physician Order Sheet " a nurse took an order that read " initiate seclusion for severe agitation /harmful behaviors to self and others " that was taken by the RN from the physician, however the physician never signed, dated nor timed the order.

Based on record review, interview, policy review, and medical staff bylaws, the facility failed to ensure that all medical records contained a discharge summary in accordance with hospital policy. Findings include:

Policy: (HIM-19 dated July 1, 2010) " All health records must be complete with all documentation of orders, diagnosis, evaluations, treatments, test results, care plans, discharge plans, consents, interventions, discharge summary, and care provided along with the patient ' s response to those treatments, interventions, and care. The record must be completed promptly after discharge in accordance with Federal and State law and hospital policy no later than 30 days after discharge ...the time frame within which the record is completed after discharge shall not exceed 30 days after discharge. "

Medical Staff Bylaws: (2012) Medical Records (N.) " The medical record must be complete within 15 days after the chart is available to the physician from the Record Room, not to exceed 30 days after discharge. Notification from the Record Room will be given to attending physicians whose discharge records have aged 8 days and remain incomplete. If ...not completed with 7 days of the notice the attending psychiatrist will temporarily lose all admission privileges ... (O.) Any psychiatrist who has remained on the list as having delinquent records for a period of four consecutive weeks will lose privileges except for present inpatients until the charts are completed. "

During review of closed medical records with Staff G (medical records) on 7-23-2012 at 2:10 pm, the following records lacked a completed discharge summary: Psychiatrist #1 had eight, Psychiatrist #4 had seven, Psychiatrist #5 had six, and Psychiatrist #2 had forty-two (dating back to February 14, 2012). For a total of 63 incomplete discharge summaries greater than 30 days post discharge. Staff G was queried as to the process that is utilized regarding incomplete discharge summaries greater than 30 days post discharge. Staff G replied, " A delinquent report is sent weekly to Staff A (CEO) and Staff B (COO). " During an interview on 7-23-2012 at 3:55 pm, Staff A was queried regarding incomplete discharge summaries greater than 30 days. Staff A replied that he sends out an e-mail to the psychiatrist and that admissions are suspended if not corrected within 5 days.

Based on document review and staff interview, the facility failed to ensure that medical records are completed within 30 days of the patient ' s discharge. Findings include:

On 7-23-2012 at approximately 2:10 pm, Staff G (medical records) generated a report of current deficient/delinquent charts greater than 30 days. The report indicated that there were currently 181 deficient/delinquent charts for 8 separate doctors with discharges dated 2-14-2012 through 6-26-2012.

This was verified by Staff G upon completion of the document review.

Based on medical record review and interview the facility failed to ensure that telephone orders are signed by a physician for 2 of 7 ( # 19, 29 ) medical records reviewed resulting in the potential for medical errors and patient harm. Findings include:
During review of the medical record for patinet # 29 on 07/25/2012 at 1600, it revealed that two telephone orders taken on 01/04/2012 had not been signed by a physician.

Based on observation, interview and policy review, the facility failed to ensure that quality controls were conducted on (4) blood glucose testing machines per manufacturer ' s recommendations resulting in the potential for erroneous results and poor patient outcomes for patients tested. Findings include:
On 7/23/12 at approximately 1140, during facility tour of Unit A found two blood glucose testing machines. Interview with Staff C on 7/23/12 at 1140 confirmed that these are used to test patients with diabetes. Staff C was asked where the quality control monitoring was documented, to which she replied " in a book at the nurses ' station " .
On 7/24/12 at approximately 0910 found in the medication room of Unit B, two blood glucose testing machines. Staff F confirmed that these machines are used to test patients with diabetes on 7/24/12 at approximately 0945. Staff F was asked where the quality control monitoring was documented for these two machines and the blood glucose testing machines on A unit, to which he replied, " I will get you copies for each unit for the last two months " .
On 7/25/12 at approximately 1430 Staff F provided four documents titled " Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record " June and July 2012 for units A & B. A single serial number was recorded at the top of each month ' s log. When asked where the rest of the quality control monitoring was for the other blood glucose machine for each unit, Staff F said " that was all there was " .
On 7/25/12 at approximately 1300 a review of facility policy titled " Blood Glucose Testing " with an effective date of July 2011 revealed that " ...F. Glucose meters are to be tested nightly for appropriate range ...Daily quality control tests will be done and documented by the midnight shift RN on each unit " .

Based on observation and interview the facility failed to ensure a sanitary and functional environment for food and medication storage resulting in the potential for unsafe food and medications for the patients served. Findings include:
On 7/23/12 at 1240, during facility tour of Unit A revealed a refrigerator that was located in the " clean utility " room with ice accumulated to over one inch in the freezer portion with residual food stains on the refrigerator shelves and freezer door shelf. Interview with Staff C on 7/23/12 at 1245 confirmed the above findings and was asked regarding who is responsible for cleaning and defrosting refrigerators, to which she replied " I ' m not sure " .
On 7/23/12 at 1250, during facility tour of Unit A revealed a room containing mostly empty drawers and a cart containing an insulated hot/cold beverage dispenser containing ice with the lid askew. Interview with Staff C on 7/23/12 at 1251 confirmed the finding and was asked how ice was dispensed to patients? Staff C replied that " they probably use a Styrofoam cup to scoop out the ice from the beverage dispenser into patient cups " .
On 7/24/12 at 0915, during medication room tour of Unit B, revealed a medication refrigerator with ice accumulated such that the freezer door would not close. This was confirmed by Staffs C and F, who indicated that " it probably could use a defrosting " .
On 7/24/12 at 0917, during medication room tour of Unit B, revealed another refrigerator used to store nutritional supplements. The temperature monitoring log located on the front of the refrigerator lacked temperature monitoring on 8 (2, 3, 4, 9, 13, 14, 15 and 19) of the 24 days of the month of July. This was confirmed by Staffs C and F on 7/24/12 at 0945.

Based on observation, interview and policy review the facility failed to ensure emergency supplies are available for use on patients when needed, resulting in the potential for poor patient outcomes for patients served by the facility requiring emergency interventions. Findings include:
On 7/23/12 at approximately 1200 during tour of Unit A revealed an emergency (crash) cart with a checklist for July/2012 that lacked monitoring documentation on the following dates: 2, 3, 4, 13, 14, 16, 17 & 20. An emergency cart checklist for June/2012 revealed that on the following dates in June there was no documentation: 15, 22, 23, 28 and 31. This was confirmed by Staff C on 7/23/12 at 1210, who replied when asked how often the cart should be checked, she replied " daily " .
On 7/25/12 at approximately 0900 a review of facility policy titled " Emergency Cart " dated July 1, 2010 revealed " ...The clinical manager or designee will be certain that these items are maintained and present on the emergency cart and in proper working order " . The policy failed to specify how often the emergency cart is checked.

Based on observation and interview the facility failed to make provisions for hand hygiene for patients on the A Unit and B Unit before meals resulting in the potential for transmission of infectious agents among the 34 patients who reside in the A Unit and the 20 patients who reside in the B Unit. Findings include:
On 7/23/12 at approximately 1220 during a tour of the A Unit revealed lunch was being served to the patients in the dining room. Staff C was asked on 7/23/12 at 1220 how patients may sanitize hands before eating, to which Staff C replied there is a bathroom immediately next to the dining room that has a hand washing sink. Access to the sink in that mentioned bathroom was restricted because the door was locked. Staff C was asked about the provision of a hand sanitizer or towelettes for patients to clean hands before eating, to which she replied, " we don't provide that, just the hand washing sink in that bathroom or in the bathroom in their (bed) rooms " .



30524

On 7/24/12 at approximately 12 noon, lunch was observed in Unit B dining area. It was observed that no sink was available for hand hygiene prior to meal consumption and there was no liquid hand sanitizer available in the dining area. On 7-25-12 at approximately 8:00 am, breakfast was observed in Unit B dining area. It was observed that no sink was available for hand hygiene prior to meal consumption and there was no liquid hand sanitizer available in the dining area.

Based on observation, the facility failed to maintain a safe and sanitary environment for patients and staff. The findings include:

During the July 24th, 2012 tour of the facility, the followings were noticed:

1. Dirt/grime and lints were visible on both wings of the patient floor common spaces and on high surfaces of the same areas. The dusty/filthy surfaces may promote the growth of infectious agents;

2. The temperature log for the nourishment refrigerator in nourishment room A327 at the A-Wing is missing the daily data entry from July 1st thru 15th, 17th, and 20th. Recording the daily temperature data is essential to determine if the food and drinks inside the refrigerator is safe for consumption or not.

Based on observation and interview the facility failed to monitor and provide a clean and sanitary environment for the 54 patients who were being served by the facility. Findings include:
On 7/23/12 during facility tour on A Unit between 1030 and 1245 revealed the following:
a). on the bed, in the seclusion room found residual tape and a sticky substance
b). in the clean utility room a patient marked bag stored in a drawer with clean patient care supplies
c). in the medication room:
1. A pen-like lancet device with lancet inserts in the blood glucose monitor case
2. A covered personal beverage container
d). in patient rooms: 303, 315, 316 and 323; dust and debris on the floors and dust accumulation along the room wall rails
e). a water pitcher used for dispensing medication at the nurses ' station, with an orange ring staining the inside bottom.
Interview with Staff C, who was escorting during the tour on 7/23/12, confirms the above findings as they were revealed. Staff C indicated that the pen-like lancet device " is never used " and she discarded it into the sharps container.
Interview with the nurse dispensing the medication, regarding who cleans the water pitchers and how often, revealed that; " I (she) don ' t know " .
On 7/24/12 during a tour of the medication room on the B Unit at 0925 revealed the following:
a). storage of personal items (a purse, vitamin water, two opened bags of " Cheeze Party Mix " , a used ceramic plate and fork and a used glass bowl with two plastic knives) in cabinets and drawers along with storage of clean patient care items
b). a pill crusher with residual white powder left in the cup
The above findings were confirmed with Staff C and Staff F on 7/24/12 at 0945.



30524

On 7-24-2012 at approximately 12 noon, lunch was observed in Unit B dining area. A male mental health tech was observed passing out several lunch trays without wearing gloves. RN B Unit Manager sent the mental health tech to do something else, she then donned gloves and began passing out the remainder of the lunch trays.

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

I. Develop and document social service assessments for 1 of 9 sample patients (A2). As a result, the treatment team did not have current baseline social functioning on this patient for establishing treatment goals and interventions. (Refer to B108)

II. Develop and document timely comprehensive multidisciplinary treatment plans to address the individual treatment needs of 2 of 9 active sample patients (B1 and B5). Specifically, the facility failed to complete treatment plans within 72 hours of admission. For patients B1 and B5, the treatment plans were not completed until 4 days after admission, and when initiated, they did not include discipline specific interventions for the psychiatrist or the nurse. This failure results in lack of care coordination and can cause delays in communicating patient specific problems and necessary staff interventions to assist patients in meeting their treatment goals. (Refer to B118)

III. Develop Master Treatment Plans for 8 of 9 active sample patients (A1, A2, A3, B1, B2, B3, B4 and B5) that identified clearly delineated interventions to address specific problems. Interventions on the treatment plans were either missing or, when written, were generic discipline related responsibilities rather than treatment interventions This failure results in lack of guidance for staff in providing individualized treatment that is purposeful and goal directed. (Refer to B122)

IV. Ensure a safe and therapeutic environment for 1 of 1 active sample patient who was placed in restraints (B5). Specifically, the facility failed to ensure safe proper use, monitoring and documentation for the patient who was restrained. There were invalid physician orders for multiple restraint episodes, incomplete or inadequate face-to-face evaluations, physical harm to the patient during one restraint, unsafe transport of the patient during restraint, and incomplete post-restraint debriefings. These failed practices are a danger to the patient and result in a restriction of the patient's right to be maintained in the least restrictive environment. (Refer to B125-I)

V. Provide adequate nursing assessment/reassessment and nursing interventions for 1 of 3 active sample patients who were suicidal (B5). The nursing staff did not adequately assess the suicide risk, and failed to notify a physician of the patient's self-harm behaviors and implement adequate observational measures for the patient's safety. These failed practices result in lack of a safe environment for patients with suicide intent. (Refer to B125-II)

VI. Dictate, transcribe and file discharge summaries within 30 days of discharge for 3 of 5 patients (D1, D2 and D3) whose discharge records were reviewed. This deficiency results in failure to communicate the final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems, and the discharge plan in a timely manner with outpatient providers. (Refer to B133)

VII. Document the date and time of follow-up appointments in the discharge summaries of 2 of 5 discharge records reviewed (D4 and D5). The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices, which they find difficult to do, and therefore may fail to do. (Refer to B134)

Based on record review, policy review and staff interviews, the facility failed to ensure that the social service assessment was completed for 1 of 9 active sample patients (A2). This results in the treatment team not having current baseline social functioning for establishing treatment goals and interventions.

Findings include:

A. Record Review

Patient A2 was admitted on 7/15/12. As of 7/24/12, there was no social service assessment present in the medical record.

B. Policy Review:

Samaritan Behavioral Center Assessment/Reassessment policy dated July 1, 2010 states "A psychosocial assessment is completed within 24 hours."

C. Staff Interviews

1. During an interview on 7/24/2012 at 1 p.m., the acting Director of Social Work stated, "I don't know why it was not done. Nobody checked off that it was not done. Check and balance system did not work here. The fatal error is that it is not done...."

2. During an interview on 7/24/2012 at 2 p.m., SW1stated, "...Today is my first day back. I completed the psychosocial assessment today." SW1 produced a completed psychosocial assessment for sample patient A2; the date on the psychosocial assessment form was 7/16/2012. When the issue of incorrect date of completion on the psychosocial assessment was brought to SW1's attention, SW1 stated, "I guess I should put today's date."

3. During an interview on 7/25/2012 at 10:15 a.m., the Medical Director stated, "I agree with you that the psychosocial assessment was not completed in a timely manner. I also agree with you that the date of completion on the psychosocial assessment was incorrect."

Based on record review and staff interview, it was determined that the facility failed to perform and document an estimate of memory functioning in the psychiatric evaluation of 1 of 9 active sample patients (B1). The failure can result in lack of identification of pathology which may be pertinent to the current mental illness, and it compromises future comparative re-examinations to assess patient's response to treatment interventions.

Findings include:

A. Record Review

Patient B1 was admitted on 07/12/2011. The psychiatric evaluation completed on 07/13/2011 did not document an estimate of memory functioning.

B. Staff Interview

During an interview on 7/25/2012 at 10:15 a.m., the Medical Director stated, "We have a format to follow when we do psychiatric evaluations. Sometimes my medical staff does not follow that format...I agree with you that an estimate of memory functioning (for patient B1) is missing."

Based on record review and staff interview, it was determined that the facility failed to document an inventory of assets in the psychiatric evaluation of 1 of 9 active sample patients (B1). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy.

Findings include:

A. Record Review

Patient B1 was admitted on 07/12/2011. The psychiatric evaluation completed on 07/13/2011 did not document an inventory of assets.

B. Staff Interview

During an interview on 7/25/2012 at 10:15 a.m., the Medical Director stated, "We have a format to follow when we do psychiatric evaluations. Sometimes my medical staff does not follow that format..."

Based on record review and interview, the facility failed to develop and document timely comprehensive multidisciplinary treatment plans to address the individual treatment needs of 2 of 9 active sample patients (B1 and B5). Specifically, the facility failed to complete treatment plans within 72 hours of admission. For patients B1 and B5, the treatment plans were not completed until 4 days after admission, and when initiated, they did not include discipline specific interventions for the psychiatrist or the nurse. This failure results in lack of care coordination and can cause delays in communicating patient specific problems and necessary staff interventions to assist patients in meeting their treatment goals.

Findings include:

A. Record Review

1. Patient B1, admitted 7/12/2012, did not have a Master Treatment Plan completed until 7/16/2012, which was 4 days after admission. In addition, the treatment plan had no psychiatrist or nursing interventions for problem #1 "psychosis"; for problem #2 "agitation," there were generic psychiatric interventions listed as "meds and psychotherapy," and no nursing interventions. The Master Treatment Plan also had no psychiatrist or nursing signatures in the section on the form titled "participating treatment team member signatures."

2. Patient B5, admitted 7/11/2012, did not have a Master Treatment Plan completed until 7/15/2012, which was 4 days after admission. In addition, the treatment plan had no psychiatric interventions identified for problem #1 "auditory hallucinations"; problem #2 "suicidal with plan" and problem #3 "hostility and threatening language/behavior towards staff." The MTP of 7/15/12 had no psychiatrist signature. The treatment plan review, completed on 7/21/2012, also had no psychiatrist signature listed on the section titled "participating treatment team member signatures."

3. Facility policy titled "Treatment Plan," 3.12 states, effective 7/1/2012, states, "The RN is responsible for initiating and updating the interdisciplinary plan under the direction of the physician within 72 hours of admission. The attending psychiatrist completes the psychiatric evaluation of the patient within 24 hours of admission and reviews the initial individualized plan of service within 72 hours with the interdisciplinary team."

4. The Individualized Plan of Service (Master Treatment Plan) Form, revised March 14, 2012, states in header section "To be completed within 72 hours."

B. Interview

1. In an interview on 7/24/2012 at 3:45 p.m., the Director of Nursing stated, "We have a lot of work to do with treatment plans. It does not surprise me that treatment plans are not done."

2. In an interview on 7/25/2012 at 10:15 a.m., the Medical Director agreed that the treatment plans are not always done in a timely way. He stated. "I am aware of the lack of psychiatric interventions on the treatment plans..."

Based on record review and interviews, the facility failed to develop Master Treatment plans for 8 of 9 active sample patients (A1, A2, A3, B1, B2, B3, B4 and B5) that identified clearly delineated interventions to address specific problems. The interventions were either missing or were generic discipline related responsibilities rather than individualized interventions. Specifically, there were: a) no psychiatrist interventions on 3 of 9 active sample patient's plans (B1, B4 and B5). The psychiatrist interventions on 5 treatment plans (A2, A3, B1, B2 and B3) were routine, generic functions listed as interventions; b) no nursing interventions on 5 of 9 active sample patient's plans (A1, A2, A3, B1 and B4) and c) no social work interventions on 1 of 9 active sample patient's plan (A2). These deficiencies result in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed.

Findings include:

A. Record Review

1. Patient B4 (admitted 6/30/2012). The Master Treatment Plan (MTP), completed 7/2/2012, had no listed psychiatrist interventions for problem #1 "delusions with hallucinations" or for problem #2 "potential harm to self/suicidal ideation." There were no nursing interventions listed for problem #2 "potential harm to self/suicidal ideation."

2. Patient B3 (admitted 7/10/12). The MTP, completed 7/12/2012, had the following generic psychiatrist's interventions: "decrease psychosis and antipsychotics" for problem #1 "auditory hallucinations;" and "antidepressants and one to one [session]" for problem #2 "suicidal ideation with plan."

3. Patient B5 (admitted 7/11/2012). The MTP, completed 7/15/2012, had no psychiatrist interventions for problem #1 "auditory hallucinations," problem #2 "suicidal with plan" or problem #3 "hostility and threatening language/behavior towards staff."

4. Patient B1, admitted 7/12/2012, MTP completed 7/16/2012, had no psychiatrist interventions for problem #1 "psychosis." For problem #2 "agitation," generic interventions for the psychiatrist included "meds and psychotherapy." For both problems #1 "psychosis" and #2 "agitation," there were no nursing interventions identified.

5. Patient A2 (admitted 7/15/2012). The MTP, completed 7/16/2012, had generic psychiatrist interventions "one to one and meds" for both problem #1 "psychosis" and problem #2 "suicidal ideations." For problem #2 "suicidal ideations," there were no nursing interventions identified. There were no social work interventions documented on the plan for either problem.

6. Patient A1 (admitted 7/16/2012). The MTP, completed 7/18/2012, had no nursing interventions identified for the medical problems of hypertension, poly-substance abuse, and chronic back pain.

7. Patient B2 (admitted 7/17/2012). The MTP, completed 7/19/2012, had generic psychiatrist interventions listed as "one to one and meds" for problem #1 "suicidal ideation with intent/plan" and problem #2 "depression/anxiety related to grief/loss."

8. Patient A3, admitted 7/18/2012, MTP completed 7/20/2012, had generic psychiatrist interventions listed as "one to one and meds" for problem #1 "psychosis," and problem #2 "potential harm to self and others." No nursing interventions were listed for either of these problems.

9. Facility policy, "Treatment Plan," 3.12, effective 7/1/2012, states "Specific interventions that relate to the achievement of treatment goals" will be documented on the Interdisciplinary Treatment Plan.

B. Interviews

1. During interview on 7/24/2012 at 11:45 a.m., after reviewing the treatment plans for his patients B1, B4 and B5, attending physician MD#1 stated, "There are no interventions identified by me; maybe I missed the form when it was passed around."

2. During an interview on 7/24/2012 at 3:45 p.m., the Director of Nursing stated, "RN should have interventions listed for all problems identified." After reviewing the treatment plans for patients A1, A2, A3, B1 and B4, the DON stated, " There are no nursing interventions written."

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

I. Ensure a safe and therapeutic environment for 1 of 1 active sample patient who was placed in restraints (B5). Specifically, the facility failed to ensure safe proper use of restraint, and subsequent monitoring and documentation for the patient who was restrained. There were invalid physician orders for multiple restraint episodes, incomplete or inadequate face to face evaluations, physical harm to the patient during one restraint episode, unsafe transport of the patient during restraint, and incomplete post-restraint debriefings. These failed practices are a danger to the patient and result in a restriction of the patient's right to be maintained in the least restrictive environment.

II. Provide adequate nursing assessment/reassessment and nursing interventions for 1 of 3
active sample patients who were suicidal (B5). The nursing staff did not adequately assess the suicide risk, failed to implement adequate observational measures for the patient's safety, and failed to notify a physician of the patient's self-harm behaviors. These failed practices result in lack of a safe environment for patients with suicide intent.

Findings include:

I. Restraint Episodes of Patient B5

A. During an interview with patient B5 on 7/24/2012 at 8:45 a.m., the patient showed the surveyor marks on the inner right upper extremity, which patient reported were obtained during a restraint procedure on 7/17/2012. The surveyor observed a series of 5 different circular markings on the inner right upper extremity, each approximately the size of a finger-tip imprint. The patient also stated s/he had filed a formal complaint with the Recipient Rights Representative regarding "being slapped in the face and bruises on arm."

B. Review of the Recipient Rights Representative file for the complaint made by patient B5 on 7/18/2012 regarding being "slapped in the face and bruises on arms" revealed pictures taken twenty four hours after the restraint incident described by the patient. These pictures show 5 finger tip sized imprints along the patient's inner right upper extremity.

C. During an interview on 7/24/2012 at 10:55 a.m., the Recipient Rights Representative reported that she received the complaint from patient B5 on 7/19/2012 and initiated an investigation. "(B5) reported to me that [s/he] was slapped in the face and had bruises on the arm after being restrained. The patient showed me the bruises on the right arm which I saw. I did not see any marks on [his/her] face. Here are the pictures that were taken of the patient's arm and face." When asked whether the Director of Nursing or Medical Director participated in the investigation, the response was "I don't know what they did; I think the Nurse Manager talked to the patient."

D. During a review of the facility security videotapes on 7/24/2012 at 12:30 p.m. in the presence of the Security Manager, it was determined that on 7/17/2012 at 12:15 a.m., the patient pounded his/her fists on the nurse's station desk, walked away to the far end of the corridor, calmed down and was sitting on the window seat; the patient was approached by 4 male mental health technicians and one female RN, and was physically held to receive prn (as needed) medication. In addition the videotapes revealed that on 7/18/2012 (9:30 a.m. - 9:43 a.m.) the staff utilized improper technique for transporting Patient B5 from the patient's bedroom, to the seclusion area to apply mechanical restraints. Three staff members were observed carrying the patient (B5) by the patient's wrists and ankles, with the patient in a supine position. There was no support of the patient's head, neck or trunk throughout the transport.

E. Review of Patient B5's medical record revealed the following:

1. Patient B5, admitted 7/11/2012, had seven separate episodes of restraint (mechanical/leather restraints or physical hold) between 7/12/2012 and 7/18/2012. The physician orders for the restraints were either incomplete or not valid due to the fact that there was no physician identified in the telephone or verbal orders written by nursing. None of the seven orders met the policy requirement: as of 7/24/2012 the orders were not countersigned by a physician.

a. A telephone order written on 7/12/2012 at 3:40 p.m. for physical hold had no physician signature as of 7/24/2012.

b. A telephone order written 7/12/2012 at 3:40 p.m. for prn medication administration had no physician signature as of 7/24/2012. In addition, this order did not specify what type of prn medication was to be administered at this particular time. The order read "hold to receive ordered prn medication."

c. A telephone order written by nursing on 7/13/2012 at 11:45 a.m. for physical hold and 4 point restraints had no ordering physician identified.

d. A telephone order written on 7/14/2012 at 5:50 p.m. for physical hold had no physician signature as of 7/24/2012.

e. A verbal order written by nursing on 7/17/12 at 11:45 a.m. for leather restraints (4 points) had no indication for use included in the order and had no ordering physician identified in the order, and no physician signature as of 7/24/2012.

f. An order written by nursing on 7/17/2012 at 12:15 a.m. for a physical hold had no ordering physician identified in the order obtained by nursing. This order also did not indicate whether the order was verbal or telephone and did not have a physician signature as of 7/24/2012. In addition, there was no order written for the medication administered to the patient during this episode.

g. A telephone order written 7/18/2012 at 9:30 a.m. for leather restraints (4 points) had no indication for use included in the order and had no ordering physician identified in the order written by nursing. This order also had no physician signature as of 7/24/2012.

2. Face to face evaluations by a physician or a trained nurse were not completed for the following restraint episodes: 7/17/2012 and 7/18/2012. None of the face to face evaluations completed by the trained Registered Nurse were reviewed and signed by the attending psychiatrist within 24 hours of the episode as per facility policy.

F. Review of facility policy titled "Restraints, 2.4," effective 2/1/2011, revealed the requirement that all verbal/telephone orders be countersigned by a physician within twenty four hours of receipt.

G. The facility form titled "Seclusion/Restraint Documentation," effective June 3, 2011, requires a physician review to be done for all patients' who have been restrained. This review is to be documented on the form as evidenced by the physician signature.

H. During review of the face to face documentation forms for patient B5 with MD1 on 7/24/2012 at 11:45 a.m., MD1 stated, "I think they are to be signed in 24 hours. I see I did not do that, but often times they do not get signed until the chart goes to medical records."

I. Facility policy for "Restraints," 2.4, effective 7/1/2011, states, "Debriefing should occur within 24 hours of release from restraint, when possible by the charge nurse or designee." Debriefing post restraint was not done for four of the restraint episodes for patient B5 (7/12/2012, 7/14/2012, 7/17/2012 and 7/18/2012). Blank debriefing forms were placed in the medical record after the restraint documentation for each of these episodes without notation regarding why a debriefing could not be done.

J. Facility policy, "Restraints" 2.4, effective 7/1/2010, states, "There must be a written physicians order for each use of physical restraint. Verbal orders for restraints are documented on the Physician Order form and must be signed by the physician within 24 hours with signature, date and time." The policy also states the physician order must specify "maximum length of time the restraint can be used, reason for restraint, type of restraint used, the behaviors which made use of restraint necessary." In addition, the policy describes the debriefing process that is to be following post-restraint: "(It) should occur within 24 hours of the release, by the charge nurse or designee."

K. Additional Interviews

1. In an interview on 7/24/2012 at 11:45 a.m., when questioned about the role of the physician in ordering restraints, MD1stated, "The nurses call me to get orders; they tell me what the behavior of the patient is." When shown the face to face evaluations and orders written on the chart for patient B5, and asked about the policy for review and/or signature by physicians. MD1 stated, "These are to be signed by the doctor I think in 24 hours. I see I didn't do that...When we do not sign them on the unit, we get them when the chart goes to medical records to complete." When shown orders written on the same chart that did not include a physician name as the originator of the order written by nursing, MD 1 stated, "That's a problem; I think they call me for orders every time a patient needs to be restrained or medicated."

2. During an interview on 7/24/2012 at 3:45 p.m., the Director of Nursing validated that the orders for restraints written on 7/13/12 at 11:15 a.m., 7/14/12 at 5:50 p.m., 7/17/2012 at 11: 45 a.m., 7/17/2012 at 12:15 a.m. and 7/18/2012 at 9:30 a.m. were not valid verbal or telephone orders. The DON stated, "The nurse is to document who they took the order from, they are to include the type of restraint to be used and the rationale for use in all orders but I can see we did not do that...I have revised the policy for restraint and seclusion but staff has not been trained on the revised policy yet." During the interview with the Director of Nursing and the Nurse Manager on 7/24/2012 at 4:20 p.m., when the surveyor related the technique that was observed (via videotape) used by facility staff to transport patient B5 (who was being put in restraint), both the DON and the Nurse Manager stated, "This is not the procedure to be followed when transporting a patient."

3. During an interview on 7/25/2012 at 10:15 a.m., the Medical Director reported that he had just been told by the Director of Nursing that "there were restraint applications done without a physician order." The Medical Director also stated, "I agree this is a serious issue that needs to be addressed with medical and nursing staff."

II. Nursing Assessment and Interventions for Suicide Precautions

A. Record Review

1. Patient B5 was admitted 7/11/2012 with diagnosis of Bipolar Disorder mixed with psychotic features, and on admission reported the following to the nurse: "I feel suicidal; I will let you know if I think about trying anything." The completed suicide risk assessment identified the patient to be at "moderate risk."

2. A progress note written by the Certified Recreational Therapist on 7/12/2012 stated that the patient reported "I am feeling unsafe from myself. I am having thoughts to hang myself with sheets and running out of here." The note by the Certified Recreational Therapist stated the MD and nurse were made aware of patient threats. No changes to level of observation were noted on the record, nor was there any documentation that the nurse followed through with speaking with the doctor regarding the patient comments.

3. On 7/17/12 at 12:30 p.m., a seclusion/restraint progress note stated that the patient had been reduced from 4 point leather restraints to 2 point leather restraints for lunch. During this time the patient "attempted to cut wrist with a fork," and this behavior resulted in 4 point restraints being reapplied, although no new order was obtained. On 7/18/2012 at 9:30 a.m., another seclusion/restraint progress note stated, "(Patient) attempted to choke self with sheet." Neither of the incidents described in the record by nursing on 7/17/2012 and 7/18/2012 showed evidence that a physician had been notified of the patient's self- harm attempts.

4. Nursing staff did not initiate additional precautions for the patient per the facility policy, "Active Suicidal and General Suicide Precautions," 2.9, effective 1/1/2005. This policy states, "the registered nurse will inform the physician within one hour of the patient's change in status."

E. Review of the facility incident reports for the month of July 2012 revealed that there had not been an incident report filed for the 7/17/2012 nor the 7/18/2012 self harm incidents for patient B5.

B. Interview

1. During an interview on 7/24/2012 at 11:45 a.m., MD#1, the attending physician for B5, stated "I believe this patient (B5) was put on a one-to-one on admission." After reviewing his progress notes, MD1 stated, "I was wrong, the patient was not (put on 1:1 observation). Now I recall, after I saw the patient I never really thought the patient was a true risk. I believe the patient's suicidality was not due to depression but more a result of a learning disability. When the patient was not coping well the patient would become more labile and suicidal." When asked if he had been notified of the patient's self-harm incidents on 7/17/2012 or 7/18/2012, MD#1 stated, "I was not; maybe if I was aware, especially of the incident with the sheets around the patient's neck, this would have been viewed differently and certainly may have warranted a one-to-one."

2. During an interview with the Director of Nursing on 7/24/2012 at 3:45 p.m. the two incidents of self-harm were reviewed. The DON stated, "The doctor should have been made aware of both of these incidents."

3. During an interview on 7/25/2012 at 10:15 a.m., the Medical Director reported to the surveyor that he saw this "as a liability to the physician and to the facility that the nurses are not informing the physician of changes in patient condition." Based on the incidents described, the Medical Director stated, "The incidents would have justified a more intense level of monitoring such as a one-to-one."

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge for 3 of 5 patients whose discharge records were reviewed (D1, D2 and D3). This deficiency results in failure to communicate in a timely manner, the final diagnosis, current medications, course of treatment, summary of relevant labs and testing, and anticipated problems and discharge plan with outpatient providers.

Findings include:

A. Record Review

Patient D1 was discharged on 6/16/12. As of 7/24/12, there was no discharge summary present in the medical record.

Patient D2 was discharged on 6/15/12. As of 7/24/12, there was no discharge summary present in the medical record.

Patient D3 was discharged on 6/11/12. As of 7/24/12, there was no discharge summary present in the medical record.

B. Policy Review

Samaritan Behavioral Center Delinquent Health Records policy dated July 1, 2010 states, "The record must be completed promptly after discharge in accordance with Federal and State law and hospital policy no later than 30 days after discharge."

C. Staff Interview

During an interview on 7/25/2012 at 10:15 a.m., the Medical Director stated, "I'm aware of the medical record delinquent situation. It has been my concern. Non-compliance is regularly communicated to the medical staff...."

Based on record review and staff interview, it was determined that the facility failed to ensure that follow-up appointments were included in the discharge summaries for 2 of 5 patients (D4 and D5) whose discharge records were reviewed. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do.

Findings include:

A. Record Review

1. Patient D4 was discharged on 6/11/12. Discharge summary dictated on 7/5/2012 did not include the date and time for follow-up appointments.

2. Patient D5 was discharged on 6/18/12. Discharge summary dictated on 7/4/2012 did not include the date and time for follow-up appointments.

B. Staff Interview

During an interview on 7/25/2012 at 10:15 a.m., the Medical Director stated, "I agree with you that the date and time for follow-up appointments should be there."

Based on record review, policy review and interviews, it was determined that the Medical Director failed to adequately monitor and evaluate the care provided to patients at the facility. The Medical Director failed to assure that:

I. A social service assessment was completed for 1 of 9 active sample patients (A2). This failure results in the treatment team not having current baseline social functioning to establish treatment goals and interventions. (Refer to B108)

II. Physicians performed and documented an estimate of memory functioning in the psychiatric evaluation of 1 of 9 active sample patients (B1). Failure to document specific testing can lead to failure to identify pathology which may be pertinent to the current mental illness, and it compromises future comparative re-examination to assess patient's response to treatment interventions. (Refer to B116)

III. Physicians documented an inventory of assets in the psychiatric evaluation of 1 of 9 active sample patients (B1). Failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in the therapy. (Refer to B117)

IV. Comprehensive multidisciplinary treatment plans were developed and documented for 2 of 9 active sample patients (B1 and B5). This failure can result in lack of care coordination and delays in communicating patient specific problems and necessary staff interventions to assist patients in meeting their goals. (Refer to B118)

V. The treatment plans of 8 of 9 active sample patients (A1, A2, A3, B1, B2, B3, B4 and B5) identified clearly delineated interventions to address specific problems. This failure results in lack of guidance for staff in providing individualized patient treatment that is purposeful and goal directed. (Refer to B122)

VI. A safe and therapeutic environment was provided for 1 of 1 active sample patient who was placed in restraints (B5). Specifically, the facility failed to ensure safe proper use, monitoring and documentation for the patient who was physically and chemically restrained. There were invalid physician orders for multiple restraint episodes, incomplete or inadequate face to face evaluations, and unsafe transport of the patient during restraint, and incomplete post-restraint debriefings. These failed practices result in potential danger to the patient and restrict the patient's right to be maintained in the least restrictive environment. (Refer to B125-I)

VII. Discharge summaries were dictated, transcribed and filed within 30 days of discharge for 3 of 5 patients (D1, D2 and D3) whose discharge records were reviewed. This deficiency results in failure to communicate in a timely manner, the final diagnosis, current medications, course of treatment, summary of relevant labs and testing, and anticipated problems and discharge plan with outpatient providers. (Refer to B133)

VIII. The follow-up appointments were included in the discharge summaries for 2 of 5 patients (D4 and D5) whose discharge records were reviewed. The lack of a definite follow-up appointment forces patients who may still be compromised in their ability to act for themselves to negotiate with agencies or offices which they find difficult to do, and therefore may fail to do. (Refer to B134)

Based on observation, record review and interview, the Director of Nursing failed to ensure that nursing staff followed acceptable standards of practice. Specifically, the DON failed to assure that nursing staff:

I. Actively participated in the development and on-going revisions of the Master Treatment Plans of 5 of 9 active sample patients (A1, A2, A3, B1 and B4). This failure results in lack of direction to nurses in providing individualized care.

II. Completed all needed nursing assessments/interventions for 1 of 3 active sample patients (B5) who were suicidal. The patient was assessed on admission with suicidal ideation and continued to express and demonstrate acts of self-harm. The nursing staff did not adequately assess the suicide risk, failed to implement adequate observational measures for the patient's safety, and failed to notify a physician of the patient's self-harm behaviors. These failed practices result in lack of a safe environment for patients with suicide intent.

III. Provided a safe and therapeutic environment for 1 of 1 active sample patient (B5) who was placed in restraints on several occasions. There were invalid physician orders for multiple restraint episodes, incomplete or inadequate face-to-face evaluations, physical harm to the patient during one restraint episode, unsafe transport of the patient during restraint, and incomplete post-restraint debriefings. These failed practices are a danger to the patient and result in a restriction of the patient's right to be maintained in the least restrictive environment.

IV. In addition, the DON failed to assure that incident reports were filled out by nursing staff and properly responded to by nursing administration. This failure results in lack of clinical oversight of patient safety.

Findings include:

I. Lack of Nursing Interventions on Treatment Plans

A. Record Review

1. Patient B4 (admitted 6/30/2012). The Master Treatment Plan (MTP) completed 7/2/2012 had no nursing interventions listed for problem #2 "potential harm to self/suicidal ideation."

2. Patient B1 (admitted 7/12/2012). The MTP completed 7/16/2012 had no nursing interventions for problems #1 "psychosis" and #2 "agitation."

3. Patient A2 (admitted 7/15/2012). The MTP completed 7/16/2012 had no nursing interventions for problem #2 "suicidal ideations."

4. Patient A1 (admitted 7/16/2012). The MTP completed 7/18/2012 had no nursing interventions for the medical problems of hypertension, poly-substance abuse and chronic back pain.

5. Patient A3 (admitted 7/18/2012). The MTP completed 7/20/2012 had no nursing interventions for problem #1 "psychosis" and problem #2 "potential harm to self and others."

B. Interviews

In an interview on 7/24/2012 at 3:45 p.m., the Director of Nursing stated, "RN should have interventions listed for all problems identified." After reviewing the treatment plans for patients A1, A2, A3, B1 and B4, the DON stated, "There are no nursing interventions written." The DON also said, "We have a lot of work to do with treatment plans..."

II. Inadequate Suicide Assessments/Nursing Interventions

A. Record Review

1. Patient B5 was admitted 7/11/2012 with diagnosis of Bipolar Disorder mixed with psychotic features. On admission, the patient reported to the nurse "I feel suicidal; I will let you know if I think about trying anything." The completed suicide risk assessment identified the patient to be at "moderate risk."

2. A progress note written in the patient's medical record on 7/12/2012 by the Certified Recreational Therapist stated that the patient reported, "I am feeling unsafe from myself. I am having thoughts to hang myself with sheets and running out of here." The note by the Certified Recreational Therapist stated that the MD and nurse were made aware of patient threats. There were no changes in the level of observation noted on the record.

3. On 7/17/12 at 12:30 p.m., the Seclusion/Restraint documentation record stated that the patient had been reduced from 4 point leather restraints to 2 point leather restraints for lunch. According to the record, during this time, the patient "attempted to cut wrist with a fork." This behavior resulted in 4 point restraints being reapplied. On 7/18./2012 at 9:30 a.m., another Seclusion/Restraint documentation stated, "(Patient) attempted to choke self with sheet." Neither of the incidents described in the record by nursing on 7/17/2012 and 7/18/2012 documented that a physician had been notified of the patients self- harm. Nursing staff also did not initiate additional precautions as per the facility policy, "Active Suicidal and General Suicide Precautions," 2.9 effective 1/1/2005. This policy states, "The registered nurse will inform the physician within one hour of the patients change in status."

B. Interview

1. During an interview on 7/24/2012 at 11:45 a.m., when asked if he had been notified of the patient's self-harm incidents on 7/17/2012 or 7/18/2012, MD#1 stated, "I was not; maybe if I was aware, especially of the incident with the sheets around the patient's neck, this would have been viewed differently and certainly may have warranted a one-to-one."

2. During an interview with the Director of Nursing on 7/24/2012 at 3:45 p.m., the two incidents of self-harm were reviewed. The DON stated, "The doctor should have been made aware of both of these incidents."

2. During an interview on 7/25/2012 at 10:15 a.m., the Medical Director reported to the surveyor that he saw this "as a liability to the physician and to the facility that the nurses are not informing the physician of changes in patient condition." Based on the incidents described, the Medical Director stated, "The incidents would have justified a more intense level of monitoring such as a one to one."

III. Restraint Episodes of Patient B5

A. Record/document Review

1. Review of Patient B5's record showed that the patient, admitted 7/11/2012, had seven separate episodes of restraint (mechanical or physical hold) between 7/12/2012 and 7/18/2012. There were 4 orders written by nursing which did not identify the physician who gave the order, and one order that did not provide a valid medication order (name of drug, dose and route). In addition, one order was not written to cover a medication given to the patient.

a. A telephone order written by nursing on 7/12/2012 at 3:40 p.m. for prn medication administration did not specify what type of prn medication was to be administered at this particular time. The order read "hold to receive ordered prn medication."

b. A telephone order written by nursing on 7/13/2012 at 11:45 a.m. for physical hold and 4 point restraints had no ordering physician identified.

c. A verbal order, written by nursing on 7/17/12 at 11:45 a.m., for leather restraints (4 points) had no indication for use included in the order and had no ordering physician identified in the order.

d. A physician order, written by nursing on 7/17/2012 at 12:45 a.m., for a physical hold had no ordering physician identified in the order obtained by nursing. This order also did not indicate the type of order--whether verbal or telephone. In addition, there was no order written for the medication administered to the patient during this episode.

e. A telephone order written by nursing on 7/18/2012 at 9:30 a.m. for leather restraints (4 points) had no indication for use included in the order and had no ordering physician identified in the order.

2. Review of facility policy titled "Restraints, 2.4," effective 2/1/2011, revealed the requirement that all verbal/telephone orders be countersigned by a physician within twenty four hours of receipt.

3. A review of the facility CSI (Clinical Service Indicators) Dashboard for 2012, demonstrated 0% compliance with restraint protocols for the month of April and 17% compliance for the month of May. There were no data reported on the dashboard for the month of June.

B. Observation

In a review of the facility security videotapes on 7/24/2012 at 12:30 p.m., in the presence of the Security Manager, it was determined that on 7/18/2012 (9:30 a.m. - 9:43 a.m.) the staff utilized improper technique for transporting a patient (B5) from his/her bedroom to the seclusion area to apply mechanical restraints. Three staff members were observed carrying the patient (B5) by the patients' wrists and ankles, in a supine position. There was no support of the patients head, neck or trunk throughout this transport. In addition, the tapes revealed that on 7/17/2012 at 12:15 a.m., the patient demonstrated an episode of pounding fists on the nurses' station desk, walked away to the far end of the corridor, calmed down and was sitting on the window seat, yet was approached by 4 male mental health technicians and one female RN, and was physically held to receive prn (as needed) medication.

C. Interview

1. In an interview on 7/24/2012 at 1545 (3:45 p.m.), the orders for restraint and medication for patient B5 were shown to the DON. After reviewing the orders, the DON stated, "A telephone or verbal order should include the name of the physician giving the order. All restraint orders should include the type of restraint to be used, the duration of the restraint and the rationale or reason for restraint. Medication orders should always include the name of the medication, route and dose." The DON acknowledged that the orders, as written, did not meet the facility's policy requirement for telephone or verbal orders. The DON also agreed that no physician name was identified as part of the orders reviewed for patient B5 (7/12/2012, 7/13/2012, 7/17/2012 and 7/18/2012).

2. During an interview with the Director of Nursing and the Nurse Manager on 7/24/2012 at 4:20 p.m., when the surveyor related the technique that was observed (via videotape) used by facility staff to transport patient B5 during restraint, both the DON and the Nurse Manager stated, "This is not the procedure to be followed when transporting a patient."

3. During an interview on 7/25/2012 at 10:15 a.m., the Medical Director reported that he had just been told by the Director of Nursing that "there were restraint applications done without a physician order." The Medical Director also stated, "I agree this is a serious issue that needs to be addressed with medical and nursing staff."

IV. Deficient Incident Reports

A. Document Review

1. Review of the facility incident reports for the month of July 2012 revealed that there had not been an incident report filed for the 7/17/2012 nor the 7/18/2012 self harm incidents for patient B5.

2. The facility policy titled, "Incident Reports," MH-35, effective 1/1/2005 states, "suicide attempts will be reported immediately to the Director of Nursing and the Medical Director."

3. During an interview on 7/24/2012 at 3:45 p.m., the Director of Nursing stated that she was the person responsible for nursing leadership within the organization, but that she reported to the Chief Nursing Officer, who had responsibility at the current time for "regulatory and quality." The DON said, "I have responsibility for the day to day operations of the nursing department."

During this same interview, the DON was asked whether she had seen incident reports related to two incidents of self harm by a patient (B5). The DON replied, "I do not recall seeing an incident report on these and I was not aware of these incidents. That does not mean an incident report was not done, they may have gone to the Chief Nursing Officer, who has the ability to manage the report. I only have the ability to read the reports, but I do not recall these." When questioned regarding her role in review of restraint incidents and her knowledge of whether or not audits have been completed for the July restraint episodes, the DON stated, "That is the nurse manager's role; I don't know if he has done them; we will need to ask him." The DON stated that the nurse manager reports directly to her.

When asked if she (DON) was aware of a patient's (patient B5) allegations related to an assault during restraint (bruising on arm and being slapped on the face), the DON stated, "I did not see an incident report, and I do not recall if I got an email notification from the Recipient Rights Representative."

The Nurse Manager, who was participating in the above interview with the DON, was asked what his review of the July incidents had shown for patient B5; the Nurse Manager replied, "I have not had the opportunity to review any of the restraint episodes for the month of July because we were revising the audit tool, and every time I tried to get the chart someone else had it."

A review of the facility training related to nonviolent crisis intervention, indicates that staff are trained in Crisis Prevention Intervention (CPI); the method of transport of patient (B5) down the corridor on 7/18/2012 at 0930-0943 is not outlined in the CPI training manual. In addition, during the same interview with the Director of Nursing and Nurse Manager on 7/24/2012 when the surveyor related the technique that was observed to be used on the video by facility staff, both stated "this is not the procedure to be followed when transporting a patient." When specifically asked if they (DON and Nurse Manager) observed this video after the patient complaints they both individually stated "no."