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Based on record review and interview, the hospital failed to ensure the hospital licensing regulations were followed by having social services provided by a licensed professional counselor rather than a licensed clinical social worker for 5 of 6 psychiatric patient records reviewed for psychosocial assessments from a total of 7 sampled psychiatric patients (#8, #9, #11, #12, #24). Findings:

Review of Patient #8 ' s medical record revealed the psychosocial assessment was performed on 07/26/10, with no documented evidence of the time it was performed, by Licensed Professional Counselor (LPC) S16.

Review of Patient #9 ' s medical record revealed the psychosocial assessment was performed on 07/26/10, with no documented evidence of the time it was performed, by LPC S16.

Review of Patient #11 ' s medical record revealed the psychosocial assessment was performed on 07/27/10, with no documented evidence of the time it was performed, by LPC S16.

Review of Patient #12 ' s medical record revealed the psychosocial assessment was performed on 07/29/10, with no documented evidence of the time it was performed, by LPC S16.

Review of Patient #24's medical record revealed the psychosocial assessment was performed on 07/21/10, with no documented evidence of the time it was performed, by LPC S16.

Review of LPC S16's personnel file revealed she was licensed as a licensed professional counselor.

In a face-to-face interview on 08/03/10 at 2:45pm, PPS-Exempt (partial payment system) Psychiatric Unit Director of Nursing (DON) S4 confirmed LPC S16 was a licensed professional counselor and not a licensed clinical social worker (LCSW). She could offer no explanation for the psychosocial assessments being performed by a LPC and not a LCSW.

Review of the hospital policy titled "Scope Of Service - Social Worker", submitted by Psychiatric DON S4 as the current policy for psychosocial assessments, revealed, in part, "...Social workers at the Unit are required to have a Masters Degree in Social Work from an accredited school of social work. They must be license eligible in the State of Louisiana. As clinical social workers they are responsible for: Admissions Process: 1. Obtaining a social history within 72 hours (working days) of admission ...".

Based on observation and interview, the hospital failed to ensure the psychiatric outdoor unit was constructed to prevent a risk of elopement by having a porch railing attached to a trailer with 5 feet between the top of the railing to the top of the trailer roof, and once on the roof of the trailer, a patient could jump onto a neighborhood street. Findings:

Observation on 08/02/10 at 11:40am revealed the outdoor area to be used by the psychiatric patients for recreation and smoke breaks surrounded on one side by the wall of the hospital, two sides by an 8 foot 1 ? inch wooden fence, and one side partially surrounded by the wall of the hospital and partially by a trailer. Attached to the trailer was a wooden porch. The porch was 31 ? inches from the ground, and the top of the porch rail was 5 feet from the top of the trailer roof.

In a face-to-face interview on 08/02/10 at 1:30pm, Registered Nurse (RN) S13 confirmed if a patient stood on the porch rail, it would be a means of accessing the roof the of the trailer, and once on the roof, a patient could jump down and be at the neighborhood street that was adjacent to the hospital fence. S13 indicated a patient had previously attempted to elope by using this porch rail and trailer roof. She further indicated there had been no changes to the outdoor environment to prevent this from re-occurring.

Based on observation and interview, the hospital failed to ensure the psychiatric unit was maintained to assure a safe environment by having a 32 ounce bottle of disinfectant cleaner on the sink in the bathroom of room "a". Findings:

Observation on 08/02/10 at 11:10am revealed a 32 ounce bottle of HB Quat Disinfectant Cleaner Ready-To-Use on the sink in the bathroom of room "a". Further observation revealed the contents of the bottle included water, alkyl dimethyl ethylbenzyl ammonium chloride, ethoxylated C12-C15 alcohols, and tetrasodium. Further observation of the bottle revealed "Precautions: avoid eye and prolonged skin contact".

In a face-to-face interview at the time observation on 08/02/10 at 11:10am, Psychiatric Director of Nursing S4 indicated the disinfectant should not be in the patient's bathroom.

Based on observation and interviews, the hospital failed to ensure the psychiatric unit was kept clean by having a soiled towel on the sink, used soap and paper soap wrapper on the shower bench, and a bottle of shampoo, used soap and soap wrapper on the floor in the shower room on the psychiatric unit. Findings:

Observations on 08/02/10 at 11:35am revealed the following: a) a used hand towel on the sink in the shower room of the psychiatric unit; b) used soap and soap wrapper on the bench in the middle shower stall of the shower room on the psychiatric unit; and c) a bottle of shampoo, open bar of soap, and soap wrapper on the floor of the last shower stall in the shower room on the psychiatric unit.

In a face-to-face interview during the observations on 08/02/10 at 11:35am, Psychiatric Director of Nursing (DON) confirmed the above findings. She indicated that the Mental Health Tech was supposed to come back after the showers were done to clean the room.

Based on record review and interviews, the governing body failed to: 1) ensure the Medical Staff Bylaws complied with the state licensing regulations by considering a medical record delinquent 30 business days after the record had been placed in the physician ' s box rather than 30 days after discharge and 2) ensure the medical staff bylaws were followed for the suspension of physicians with delinquent medical records by allowing a suspended physician to direct admit a patient while suspended (S26). Findings:

1) Medical Staff Bylaws complied with state licensing regulations:
Review of the hospital's Medical Staff By-Laws, approved 02/24/10 and submitted by Administrator S1 as the hospital's current by-laws, revealed, in part, "...Each medical record shall be completed within 30 working days after being routed to the physician's box or the record becomes delinquent ...".

In a face-to-face interview on 08/04/10 at 2:30pm, Medical Records Supervisor S20 confirmed that the hospital's medical staff bylaws consider a medical record to be delinquent 30 business days after it was placed in the physician's box. She indicated that it usually takes 1 week after discharge before a patient ' s medical record was processed and coded by the medical record department and placed in the physician's box.

In a face-to-face interview on 08/04/10 at 3:00pm, Administrator S1 confirmed the above information presented by Medical Records Supervisor S20. He could offer no explanation for the by-laws not meeting the regulations for licensing.

In a telephone interview on 08/04/10 at 3:20pm, contracted RHIA (registered health information administrator) S22, when informed of the medical staff by-laws regarding delinquent medical records, indicated she was not aware that the hospital was considering a medical record to be delinquent 30 business days after the record had been placed in the physician's box.

Review of the Department of Health and Hospitals' Hospital Licensing Standards Chapter 93 Subchapter H. Medical Record Services 9387. Organization and Staffing revealed, in part, "J. The hospital shall ensure that all medical records are completed within 30 days following discharge...".

2) Suspended physician allowed to direct admit a patient:

Review of the "Notification Letter" sent to Physician S26 dated 05/20/10 by Administrator S1 revealed he was suspended due to having 10 delinquent charts. Further review revealed his suspension was lifted on 05/25/10.

Review of the "Admissions Report" for the period from 05/20/10 through 05/25/10 revealed 1 patient was admitted by S26 as a direct admit.

Review of a note presented by Administrator S1 and signed by S1 and Medical Records Supervisor S20 revealed "On 5/21/10, Physician S26 called in admit orders on (number of patient) as a direct admit. The pt (patient) was admitted to the floor. Physician S26 was just suspended on 5/20/10 and the letter to him was put in his box the same day. Physician S26 most likely did not get to read his suspension letter yet as it was just put in his mail box the day before this admission".

In a face-to-face interview on 08/05/10 at 8:25am, Administrator S1 could offer no explanation for the notification of Physician S26 of his suspension not reaching S26 in time to prevent the bylaws to be implemented and prevent an admission by direct admit while S26 was suspended.

Review of the Medical Staff Bylaws, approved 02/24/10 and presented by Director of Nursing S3 as the current copy of the bylaws, revealed, in part, "... Section 3: Automatic Suspension a. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges (meaning inpatient direct admits and elective surgeries), effective until medical records are completed, shall be imposed automatically on the 5th day from warning of delinquency for failure to complete medical records within 30 days of the date the chart is routed to the physician's box...".

Based on record review and interview, the hospital failed to ensure the staffing of the psychiatric unit was sufficient on the night shift on 14 of 14 days reviewed by having 1 Registered Nurse (RN) and 1 MHT (mental health technician) with a range of 8-10 patients, 3 to 6 of whom were suicidal, which resulted in the unit being left without a nurse on 2 separate occasions the night of 07/31/10 when the RN left the unit to transport and then to check on a patient in the emergency room. Findings:

Review of the staffing pattern for 07/19/10 through 08/01/10 completed by Psychiatric Director of Nursing (DON) S4 revealed the night shift was staffed with 1 RN and 1 MHT.

Review of the hospital policy for staffing the psychiatric unit revealed no documented evidence of an acuity system used to determine the need for increased staff.

Review of the "Night Report" presented by Psychiatric DON S4 revealed the following census with the number of suicidal patients per night:
07/19/10 - 10 patients, 4 of whom were suicidal;
07/20/10 - 10 patients, 4 of whom were suicidal;
07/21/10 - 10 patients, 4 of whom were suicidal;
07/22/10 - 9 patients, 4 of whom were suicidal;
07/23/10 - 8 patients, 3 of whom were suicidal;
07/24/10 - 9 patients, 4 of whom were suicidal;
07/25/10 - 10 patients, 4 of whom were suicidal;
07/26/10 - 10 patients, 5 of whom were suicidal;
07/27/10 - 10 patients, 5 of whom were suicidal;
07/28/10 - 8 patients, 3 of whom were suicidal;
07/29/10 - 9 patients, 5 of whom were suicidal;
07/30/10 - 10 patients, 6 of whom were suicidal;
07/31/10 - 10 patients, 6 of whom were suicidal;
08/01/10 - 10 patients, 6 of whom were suicidal.

Review of Patient #8's medical record revealed documentation of a late entry by RN S14 on 07/31/10 at 2105 (9:05pm) that Patient #8 fell in the day room, was dizzy and disoriented with a blood pressure of 74/46. Further review revealed Patient #8 was brought to the emergency room.

In a face-to-face interview on 08/03/10 at 8:05am, RN S14 confirmed that he personally transported Patient #8 to the emergency room and later in the shift returned to the emergency room to check on the patient. He indicated that he left the remaining 9 patients, 5 of whom were suicidal, with 1 MHT. He confirmed there was no nurse on duty in the psychiatric unit when he left the unit on 2 occasions on 07/31/10.

In a face-to-face interview on 08/03/10 at 8:40am, Psychiatric DON S4 confirmed that RN S14 did not follow hospital policy by leaving the unit without a nurse present.

In a face-to-face interview on 08/03/10 at 2:45pm, Psychiatric DON S4 indicated if staffing is adjusted, one would need to look at the acuity of patients. When asked by the surveyor how acuity was measured, S4 indicated acuity was based on diagnosis, potential for violence, whether a patient was experiencing hallucinations, and such. S4 confirmed there was no measurement criteria used to determine staffing based on acuity. When asked how she could assure safety of patients and staff if any type of disruption occurred, S4 indicated if a patient required 2 staff members to handle a crisis, she would not have the resources to handle or care for the other patients on the night shift.

Review of the hospital policy titled "Staffing Patterns/Variances/Acuity", with no documented evidence of an effective date or approval by the governing body, revealed, in part, "... The staffing pattern for the program is based on aspects of care and services provided, patient census, acuity, skill mix of staff, past experience ... to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Ultimately, the Program Director is responsible for ensuring that these patterns are communicated to department staff. It is recognized that there may always be unpredictable fluctuations in census and/or acuity. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs. A registered nurse is on duty 24 hours a day. ... In the event that the census increases, additional staff members may be called in to ensure high quality, individualized care for every patient. ... The charge nurse on duty will notify the Program Director if the census increases and additional staffing is required".

Based on record review and interviews, the hospital failed to ensure pharmacy services were administered according to accepted professional principles by failing to: 1) ensure physicians' medication orders were reviewed by a pharmacist for appropriateness before the first dose was administered for 11 of 11 patients sampled for pharmacy review prior to first dose administration from a total of 26 sampled patients (#1, #2, #3, #4, #8, #9, #10, #11, #12, #13, #24) and 2) ensure nursing medication carts on the psychiatric unit were stored in a locked room by having 2 medication carts stored in the nursing station that was a high traffic area with employees present who did not have legal access to drugs. Findings:

1) Pharmacist review of medication orders:
Patient #1
Review of the medical record of patient #1 revealed the patient was admitted on 07/30/10 at 1618 (4:18 p.m.). Review of the physicians' orders revealed documentation that the first medication was administered to patient #1 on 07/30/10 at 1710 (5:10 p.m.)
Further review of the medical record of patient #1 revealed the pharmacist did not review the medication regimen for patient #1 until 08/02/10 at 9:20 a.m. (65 hours and 2 minutes since admission).
In an interview on 08/02/10 at 1:10 p.m. with S3 DON (director of nursing), she confirmed that the medication regimen was not reviewed by the pharmacist until 08/02/10 at 9:20 a.m.

Patient #2
Review of the medical record of patient #2 revealed the patient was admitted on 07/28/10 at 2010 (8:10 p.m.). Review of the Medication Administration Record (MAR) revealed documentation that the first medication was administered to patient #2 on 07/28/10 at 9:00 p.m.
Further review of the medical record of patient #2 revealed the pharmacist did not review the medication regimen for patient #2 until 07/29/10 at 8:55 a.m. (12 hours and 45 minutes since admission).
In an interview on 08/02/10 at 1:30 p.m. with S3 DON, she confirmed that the medication regimen was reviewed by the pharmacist 07/29/10 at 8:55 a.m.
In an interview on 08/02/10 at 2:10 p.m. with S6 RPH (registered pharmacist), she confirmed that the medication regimen for patient #2 was not reviewed until 07/29/10 at 8:55 a.m. She further stated that it is the normal practice of the pharmacy to review after- hours admits' medication regimen the next day and not until Monday for patients admitted from Friday after normal hours through Monday morning.

Patient #3
Review of the medical record of patient #3 revealed the patient was admitted on 08/01/10 at 2010 (9:15 a.m.). Review of the MAR revealed documentation that the first medication was administered to patient #3 on 08/01/10 at 9:00 a.m.
Further review of the medical record of patient #3 revealed the pharmacist did not review the medication regimen for patient #3 until 08/02/10 at 9:00 a.m. (11 hours and 45 minutes since admission).
In an interview on 08/02/10 at 2:10 p.m. with S6 RPH, she confirmed that the medication regimen for patient #3 was not reviewed until 08/02/10 at 9:00 a.m.

Patient #4
Review of the medical record of patient #4 revealed the patient was admitted on 07/30/10 at 2335 (11:35 p.m.). Review of the MAR revealed documentation that the first medication was administered to patient #4 on 07/31/10 at 9:00 a.m.
Further review of the medical record of patient #4 revealed the pharmacist did not review the medication regimen for patient #4 until 08/02/10 at 9:10 a.m. (8 hours and 35 minutes since admission).
In an interview on 08/02/10 at 2:10 p.m. with S6 RPH, she confirmed that the medication regimen for patient #4 was not reviewed until 08/02/10 at 9:10 a.m.

Patient #8
Review of Patient #8's "Physician Admission Orders" revealed he was admitted on 07/24/10 at 0100 (1:00am). Review of Patient #8's "B.H.U. (behavioral health unit) - Physician Orders Medication Reconciliation/Verification Form" dated 07/24/10, with no documented evidence of the time it was received, revealed it was reviewed by Pharmacist S6 on 08/02/10, 9 days after admit.

Patient #9
Review of Patient #9's "Physician Admission Orders" revealed he was admitted on 07/23/10 at 1645 (4:45pm). Review of Patient #9's "B.H.U. (behavioral health unit) - Physician Orders Medication Reconciliation/Verification Form" dated 07/23/10 at 1645 revealed it was reviewed by Pharmacist S6 on 07/28/10 at 9:00am, more than 16 hours after admit and after Patient #9 had received medications.

Patient #11
Review of Patient #11's "Physician Admission Orders" revealed he was admitted on 07/25/10 at 2015 (8:15pm). Review of Patient #11's "B.H.U. (behavioral health unit) - Physician Orders Medication Reconciliation/Verification Form" dated 07/25/10 at 1930 (7:30pm) revealed it was reviewed by Pharmacist S6 on 07/28/10 at 8:30am, 3 days after admit.

Patient #12
Review of Patient #12's "Physician Admission Orders" revealed he was admitted on 07/28/10 at 1815 (6:15pm). Review of Patient #12's "B.H.U. (behavioral health unit) - Physician Orders Medication Reconciliation/Verification Form" dated 07/28/10 at 1815 revealed it was reviewed by Pharmacist S6 on 07/29/10 at 9:00am, more than 14 hours after admit and after Patient #12 had received medications.

Patient #24
Review of Patient #24's "Physician Admission Orders" revealed she was admitted on 05/20/10 at 1700 (5:00pm). Review of Patient #24's " B.H.U. (behavioral health unit) - Physician Orders Medication Reconciliation/Verification Form" dated 05/20/10, with no documented evidence of the time it was received, revealed it was reviewed by Pharmacist S6 on 06/01/10, 10 days after admit.

In a face-to-face interview on 08/04/10 at 1:50pm, Pharmacist S6 indicated the patients' orders were faxed to her from the behavioral unit. She further indicated she signed the medication reconciliation forms later. She further indicated signing the forms may be delayed if they're received after hours or on weekends. S6 confirmed that she was not reviewing the medications before the first dose was administered when she was out of the hospital, such as after hours or on weekends. She further confirmed that she had no way of verifying that she had reviewed the medication reconciliation forms prior to the first medication dose administered for Patients #8, #9, #10, #11, #12, #13, and #24.

Review of the hospital policy titled "Medication Reconciliation", effective May 21, 2009, policy number 57.1 with no date of last review and presented as the current hospital policy, revealed, in part, "...Purpose. D. Nursing, upon admit, and Pharmacy, prior to dispensing meds, will verify that the written order has been entered correctly in the medical record...".

Review of a hospital policy titled "Unit Dose Drug Distribution Procedures", effective January 8, 2008, policy number 84.0 with no date of approval or last review and presented as the current hospital policy, revealed, in part, "Purpose: To define policy and procedure to be followed for inpatient medication distribution.....A pharmacist is responsible to interpret the medication order, transcribe the order onto the patient medication profile, monitor the profile for potential drug-drug interactions or patient allergies and to dispense the proper medication to the correct patient...".

2) Medication carts in a locked room:

Observation on 08/02/10 at 2:00pm revealed 2 locked medication carts in the nursing station of the behavioral health unit. The nursing station had a locked door that led to the outer hall of the unit that was accessible by all hospital staff and visitors. There was a half-door leading from the nursing station to the hallway that led to the social service office to the right, the patient quiet room across from the half-door, and the hall to patient rooms on the left.

Observation on 08/02/10 at 3:45pm revealed the half-door of the nursing station ajar with a patient standing outside the door while talking to staff and another patient in the quiet room. There was no one monitoring the open half-door leading into the nursing station where the medication carts were stored.

In a face-to-face interview on 08/04/10 at 10:05am, Psychiatric Director of Nursing S4, after reviewing the regulations for storage of medication carts, indicated "we need a medication room, it's (the nursing station) a high traffic area". She further indicated at times there was staff present in the nursing station who would not have access to medications, and the noise level could be distracting to a nurse preparing medications for administration.



26458

The hospital failed to ensure that medication errors be reported immediately to the practitioner who ordered the drug for 2 of 4 medical records reviewed for medication errors in a total sample of 26 (#2, #4). Findings:

Patient #2
Review of the medical record for patient #2 revealed the physician had ordered Humulin N 30 units SQ (subcutaneously) q (every) AM upon admission on 07/28/10. Review of the Medication Administration Record (MAR) for 07/29/10 revealed the dose of insulin was "held (arrow down) BS (blood sugar). Further review of the MAR revealed #2's blood sugar was 115 (mg/DL) (milligrams per deciliter). (adult normal range 80 - 120 mg/dl)

Further review of the MAR and nurses' notes revealed no documented evidence that the physician responsible for the care of patient #2 was notified of the held dose of insulin.

In an interview on 08/02/10 at 1:30 p.m. with S3DON (Director of Nursing) she confirmed this was an omitted dose, that a medication variance report should be filled out and that there was no documented evidence that the physician was notified.

Further review of the medical record of patient #2 revealed that the physician ordered Thioridazine 50 mg (milligrams) po (by mouth) TID (three times daily). Review of the MAR revealed the 9:00 p.m. dose for 07/28/10 was marked as " * - not available".

In an interview on 08/02/10 at 1:30 p.m. with S3DON she confirmed this was an omitted dose, that a medication variance report should be filled out and that there was no documented evidence that the physician was notified.

In an interview on 08/02/10 at 1410 (2:10 p.m.) with S6RpH (Registered Pharmacist) she stated that she had no medication variance report on the Insulin or Thioridazine.

Patient #4
Review of the medical record for patient #4 revealed the physician had ordered continuation of the home medications to include Enalapril 5 mg po daily and Verapamil 240 mg po daily. (both are for blood pressure)

Review of the MAR for 08/02/10 revealed that both medications were held by the nurse due to the patient having a blood pressure of 106/58. Further review of the medical record revealed no documented evidence of notification of the physician responsible for the care of patient #4 and no medication variance report.

In an interview on 08/05/10 at 10:20 a.m. with S3DON she confirmed there was no documented evidence of notification of the physician responsible for the care of patient #4 and no medication variance report.

Review of a hospital policy, "Adverse Drug Events", effective September 22, 2006, policy number 95.0, approved by the Medical Staff and Board on 09/26/06, no last revision date, presented as current hospital policy, read in part: "Policy: Potential medication errors, medication errors.....shall be reported by the healthcare professional involved in, witnessing , or first discovering the adverse event....Definitions:....Medication Error:...Administration:....Omission...Guidelines: All actual and potential adverse drug occurrences shall be recorded on the Confidential Hospital Occurrence Report....Actions for Adverse Drug Reactions and Medication Errors. Step 1: The staff member who discovers the Adverse Drug Event will notify the Physician, Director of Nurses and the Pharmacist immediately for all medication errors.....Step 3: Documents in the medical record.....time of physician /pharmacist/director of nurses/RN supervisor notification....".

Based on record reviews ("Infection Control Committee Meeting Minutes", and Infection Control Policy and Procedure Manual) and an interview with S17, Infection Control Nurse (ICN), the hospital failed to have a system in place for identifying, investigating and controlling patients' infections as evidenced by failing to have active surveillance that included specific measures for prevention, control, investigation, corrective actions, and monitoring of the corrective actions for the urinary tract infections that were acquired through the insertion of a foley catheter at the hospital. Findings:

Based on review of the "Infection Control Committee Meeting" Minutes dated, 7/27/10 and Infection Control Nurses' interview, the hospital failed to have an active surveillance system to investigate, implement corrective actions, monitor the corrective actions implemented and evaluate the effectiveness of the program as evidenced by identifying there were 2 nosocomial infections acquired through the insertion of foley catheters. Findings:

Review of the "Infection Control Committee Meeting" dated, July 27, 2010, for the 2nd Quarter, (April, May, June) revealed there were four (4) Hospital Associated infections reported for the Acute Care Hospital. Further review revealed there were 15 foley catheters inserted during this quarter with 2 possible catheter associated infections. The patients had culture and sensitivity urinalysis tests that confirmed the two patients had acquired a urinary tract infection from the insertion of the foley catheters at the hospital. There was of the investigation performed to identify, monitor or corrective actions implemented as a result of the investigation to determine the cause of the patient ' s hospital acquired nosocomial urinary tract infections acquired from the insertions of a foley catheter.

In interview on 8/5/10 from 9:15am to 9:50am, S17, Infection Control Nurse (ICN) verified there were 2 patients reported with possible hospital acquired urinary tract infections related to the insertion of urinary catheters. S17 further indicated these infections were investigated by a physician. The physician confirmed these patients ' infections were related to the insertion of foley catheters at the hospital by urine culture and sensitivity tests. S17 reported the nursing staff was notified that 2 patients had acquired urinary tract infections when the catheters were inserted at the hospital. S17 indicated there was no action taken, yet because the meeting was held last week. S17 reported there was no training, education or in-services to the nursing staff related to the urinary catheter insertions since 7/27/10. S17 continued there was no investigation to determine the root cause of the urinary tract infections from 7/27/10 to 8/5/10. She indicated there was no active surveillance monitoring for catheter insertions being performed at the hospital from 7/27/10 until presently, 8/5/10. S17 reported there were no corrective actions implemented or monitoring of the corrective actions implemented to determine the effectiveness of the program for the urinary tract infections that were identified and reported during the 2nd quarter on 7/27/10.

Review of the policy titled, "Program Personnel", Number 1.0, effective date of January 22, 2008, reviewed dates from 2/25/10 through 3/23/10, revised dates from 1/15/09 to 2/17/09, presented as the current "Infection Control" policy and procedures, read in part, "The duties of the Infection Control Committee are to consider the reports of the infection control team, to evaluate these reports and recommendations, and to formulate a report on a quarterly basis. The Infection Control Team-This Infection Control Nurse shall be responsible for the day-to-day infection surveillance in the hospital. The team, in addition, shall review environmental surveys conducted as necessary, and shall formulate and periodically review the hospital infection control guidelines. The infection control nurse shall prepare the statistical reports, the individual suspected infection reports, and recommendations for consideration by the Infection Control Committee at its quarterly meeting".

The policy titled, "Letter of Authority", Number 2.0, effective dates from 2/25/10 through 3/23/10, revised dates from 1/15/09 to 2/17/09, presented as the current "Infection Control" policy and procedures, read in part, "The Infection Control Committee responsible for developing policy and procedures in infection control, for the control of infections within the hospital, and for the evaluation of the infection control potential of the related environment. The Infection Control Committee is granted the authority to institute any appropriate control measures when there is reasonably felt to be a danger to any patient: ...To report any actual or suspected infections, ...To initiate a culture and sensitivity testing".

Review of the policy titled, "Hand Washing", with no Number, effective dates from 2/25/10 through 3/23/10, reviewed date of 2/16/04, revised dates from 1/15/09 to 2/17/09, presented as the current "Hand Washing" policy read as follows, "Nosocomial infection is frequently spread by the most common form of contact, hand contact. The Infection Control Committee must closely monitor hand washing throughout the hospital".




25065

Based on record reviews and interviews, the hospital failed to: 1) develop a system to ensure that physicians appointed to the medical staff and nurse practitioners privileged by the medical staff were determined to be free of TB upon appointment and annually thereafter for 4 of 4 physicians ' credentialing files reviewed (S18, S25, S26, S28) and 1 of 1 nurse practitioner reviewed (S27) and 2) ensure all hospital staff were screened for TB according to CDC (Centers for Disease Control) upon hire and annually thereafter for 4 of 13 direct care workers reviewed for annual TB testing (S5, S10, S14, S23). Findings:

1) Physicians and Nurse Practitioner tested for TB:
Review of the credentialing files of Physicians S18, S25, S26, and S28 and Nurse Practitioner S27 revealed no documented evidence of TB testing upon initial appointment/privileging and annually thereafter.

In a face-to-face interview on 08/04/10 at 10:00am, Infection Control Registered Nurse S17 confirmed the hospital did not require physicians and nurse practitioners to have TB testing.

Review of the CDC ' s " Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 " revealed, in part, " ...The following are HCWs (health care workers) who should be included in a TB screening program: ...Nurses ... Physicians (assistant, attending, fellow, resident, or intern), including anesthesiologists, pathologists, psychiatrists, psychologists ... " .
2) Hospital staff tested for TB:
Registered Nurse S5
Review of Registered Nurse (RN) Charge Nurse S5 ' s " Annual Tuberculosis Screen " revealed the test was administered on 04/05/10 and read on 04/07/10. Further review revealed no documented evidence of the times of administration and reading the results, therefore there was no way to assure the reading was done at least 48 hours after administration.
In a face-to-face interview on 08/04/10 at 10:20am, Director of Nursing (DON) S3 confirmed the above findings.

S10, Housekeeping
Review of S10's " Annual Tuberculosis Screen " revealed the last annual screening test was performed on 10/3/09. Further review revealed there was no documentation of S10's last annual tuberculosis skin test performed.

In a face-to-face interview on 08/03/10 at 9:50am, Chief Financial Officer (CFO) S2 confirmed the above findings.

RN S14
Review of RN S14 ' s " Medical Examination Form " dated 06/26/06 revealed " Remarks/Recommendations: Test positive TB - not consider active TB " .
Review of the " Employee Health Tuberculosis Screening " dated 06/26/08 and 08/08/09 revealed they were reviewed by Psychiatric DON S4. Further review of the health file for RN S14 revealed no documented evidence of a chest x-ray result since the positive TB result.
In a face-to-face interview on 08/04/10 at 9:30am, Psychiatric Director of Nursing DON S4, when asked about the TB policy regarding chest x-rays if an employee had a positive TB skin test, indicated she did not feel comfortable determining if a chest x-ray was required after reviewing an employee ' s TB Health Screening tool. She further indicated she had never reviewed a tool with the understanding that she was supposed to order a chest x-ray based on the answers presented by the employee. S4 confirmed that the policy was not clear as to who had the responsibility to determine if a chest x-ray was required.
In a face-to-face interview on 08/04/10 at 10:00am, Infection Control RN S17 indicated when an employee or applicant had a previous positive TB test, she would ask if they had been treated or had a chest x-ray, and if so, she would complete the TB screening tool. She further indicated it was the responsibility of the nurse interviewing the employee/applicant to determine if a chest x-ray was needed. S17 confirmed that she did not perform duties of the Infection Control nurse for the behavioral health employees, she only reviewed behavioral health patient records for infection control issues. S17 could offer no explanation for the hospital policy not being clear regarding who would determine if a chest x-ray was needed or for the policy not following the CDC guidelines.

Certified Nursing Assistance (CNA), S23
Review of S23's " Annual Tuberculosis Screen " revealed the last annual screening test was performed on 10/13/09. Further review revealed there was no documentation of S23's last annual tuberculosis skin test performed.
In a face-to-face interview on 08/03/10 at 10:20am, Chief Financial Officer (CFO) S2 confirmed the above findings.

Review of the hospital policy titled " Employee Health Program/Screening " , effective 04/12/10 and submitted by Infection Control Registered Nurse (RN) S17 as the current hospital policy for TB testing, revealed, in part, " Pre-Employment Requirement: ... The initial requirements include: Tuberculin skin test ... is free to the new employee. If the employee is a known positive to a tuberculin skin test a TB Health Screening will be completed. After the health screening is complete, if a chest x-ray is needed, the Hospital will pay for the expenses of the chest x-ray. ... Annual Requirements: As a condition of employment, each employee is required to have an annual tuberculin skin test. If the employee is a known positive to a tuberculin skin test a TB Health Screening will be completed. After the health screening is complete, if a chest x-ray is needed, the Hospital will pay for the expenses of the chest x-ray ... As a condition of employment, each employee is required to have an annual tuberculin skin test. If the employee is a known positive to a tuberculin skin test a TB Health Screening will be completed. After the health screening is complete, if a chest x-ray is needed, the Hospital will pay for the expenses of the chest x-ray ... " .

Review of the CDC ' s " Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 " revealed, in part, " ...HCWs with a baseline positive or newly positive test result for M. tuberculosis infection or documentation of previous treatment for ... TB disease should receive one chest radiograph result to exclude TB disease. Instead of participating in serial testing, HCWs should receive a symptom screen annually. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such symptoms immediately to the occupational health unit ... " .

Based on observations, record reviews, and interviews, the CAH failed to ensure the Dietary Services met the Federal and State licensure requirements for food and dietary personnel as well as food service standards, laws and regulations and recognized dietary practices as evidenced by:
1) failed to ensure the service director was responsible for the daily management and cleanliness of the service as evidenced by having:
a) hair nets not worn in the food preparation area as per policy,
b) rust in the bottom tray of the dish washer
c) wet, orange discolored test strips to test the machine's levels during the rinse cycles,
d) white substance caked around the tubing and spouts of the washing detergent and rinse agents dispensed during the machines' washing cycles;
e) brown substances in the toaster ovens,
f) brown debris in the corner edges of the ice machine and a white and gray substance in the ice scoop's holder, and
g) a meat cutter covered with a grayish substance noted on the cutting edge of the machine;
2) failed to ensure the dish washers temperatures were maintained as per the manufacturer's instructions and the policy of 125 degrees Fahrenheit at a minimum as evidenced by: a) recording the machine's daily temperatures of 120 degrees Fahrenheit from June to August of 2010, and b) having 100 degrees Fahrenheit temperatures recorded for the machine with no interventions implemented the dietary staff (S10);
3) failed to ensure acceptable hygiene practices of food service personnel were maintained as evidenced by: a) having a soap dispenser in the snack bar area with a yellow dried substance on the dispenser, b) observance of an employee not washing her hands after touching a dirty soap dispenser (S11, Cook) and coughing into her hand (S24, Cook); and
4) failed to ensure the food temperature were maintained at 140 degrees Fahrenheit or above as evidenced by having food on the serving line and test tray with temperatures of 130 degrees Fahrenheit (mashed potatoes), 119 degrees Fahrenheit (chopped meats), 139 degrees for the barbecue chicken, 119 degrees for the baked beans, and 120 degrees for the corn bread. Findings:

1) Daily management and cleanliness of the service:

a) A tour of the kitchen was conducted on 8/2/10 from 10:45am through 11:40am with S8, Dietary Director. During this tour, S8 was observed with no hair net while plates were prepared for the patients located at the outpatient center which was an offsite of the hospital. S8 was observed wearing a pink baseball cap on 8/2/10 at 1:25pm, 8/3/10 at 8:35am, and 8/3/10 at 9:10am in the kitchen preparation area while food was being prepared by the dietary staff. In interview on 8/3/10 at 11:06am, S8 indicated hair nets are to be worn in the food preparation area, not a pink baseball cap.

b) An observation of the dish washer (Anti-Chlor) system on 8/2/10 at 2:06pm with S8 revealed there were orange spots or particles that covered an area of about 2 feet in the bottom of the pan in which all patient's plates are washed. S8 verified during this observation there were orange spots or particles in the pan. S8 indicated the orange spots were rust. S8 further indicated she had attempted to clean the rust in the pan but some of the rust spots could not be removed.

c) The Auto-Chlor test strips were observed with an orange discolored area on the tips of the strips in the container on 8/2/10 at 2:10pm with S8. Further observation revealed these test strips had the top edges of the strips folded inward. S8 indicated the test strips were wet and discolored. She further indicated these strips would give an inaccurate reading for the final rinse low water temperature of 120 degrees Fahrenheit with 50 parts per million (ppm) of hypochlorite (household bleach) on the dishes' surfaces.

d) Further observation of the Auto-Chlor machine on 8/2/10 at 2:10pm with S8 revealed there was a white substance covering the tip of the spouts and tubing of the washing detergent and rinse solutions dispensed during the washing cycle. S8 verified the tips of the spouts and tubing of the detergent and rinse solution were covered with a white substance.

e) During this same observation of the snack area on 8/2/10 at 2:30pm with S8 and S11, Cook, there was a toaster oven noted with brown debris inside each of the four (4) slots that the bread is put in to be toasted. S8 confirmed the toaster oven was dirty.

f) This same observation of the snack bar area on 8/2/10 at 2:25pm with S8 revealed there was an ice machine noted with brown debris in both corners of the machine opening to get the ice out of the machine. Further observation revealed the ice scoop was in a clear container mounted on the side of the machine. There was white and gray particles noted floating in the bottom of the container. S8 verified these findings.

g) Another observation of the kitchen area on 8/2/10 at 1:55pm with S8 revealed there was a meat cutter covered with a grayish substance noted on the cutting edge of the machine. During this observation, S8 verified the meat cutter had a gray substance covering the cutting edge of the machine.

2) Dishwasher temperatures:

During an observation on 8/2/10 at 2:06pm with S8, the machine's manufacturer's recommendations were posted on the front panel of the Anti-Chlor (dish washing) machine. The machines ' label read, "...1. Water temperature 125 degrees Fahrenheit minimum...".

Review of the daily washing temperature sheet used by all dietary staff to record the machine's washing temperature had the normal temperature of 120 degrees Fahrenheit recorded on the preprinted form. Review of the daily temperature logs from 6/1/10 through 7/1/10 revealed the dish washer had a minimum washing temperature of 120 degrees. Further review of the 7/2/10 log revealed the machine had a temperature reading of 100 degrees Fahrenheit at 6:00am and 11:00am recorded by S10. The machine had temperatures recorded as 120 degrees on the daily logs from 7/3/10 to 8/2/10. Further review of the daily log for 8/2/10 revealed a reading of 120 degrees was documented at 6:00am (0600) and there was no temperature recorded at 11:00am.

In interview on 8/2/10 at 2:15pm, S8 verified the manufacturer's recommendations posted on the Anti-Chlor (dishwasher) read, "minimum of 125 degrees Fahrenheit for the water temperature". S8 indicated she was not aware the machine's temperature was to be 125 degrees Fahrenheit since October of 2009 when she took the director's position. She further indicated the machine's daily temperature logs had the minimum temperature of 120 degrees Fahrenheit.

S8 verified the above findings on 8/2/10 at 2:50pm. S8 indicated there was no documentation of what interventions were implemented by the dietary staff (S10) on 7/2/10 at 6:00am or 11:00am when the machine's temperature was recorded as 100 degrees by S10. S8 further indicated the machine's normal temperature range was 120 degrees Fahrenheit. She reported dietary staff is to notify her when the machine's temperature is below the normal range of 120 degrees Fahrenheit. She further reported the machines' normal ranges recorded on the daily logs were 120 degrees Fahrenheit since she became the director in October of 2009. She verified the daily logs normal temperature of 120 degrees did not match what the manufacturer's recommendation was 125 degrees Fahrenheit. S8 indicated the manufacturer's recommended minimum temperature of 125 degrees should be followed and not 120 degrees that was recorded on the daily temperature logs sheet used by all dietary staff to record the machines' daily temperatures.

3) Hand hygiene practices:

An observation of the snack bar area on 8/2/10 at 2:35pm with S8 and S11, Cook revealed there was a soap dispenser mounted on the wall. Further observation revealed S11 had a pair of gloves on bilaterally and she opened the soap dispenser. There was a dry, yellow substance noted covering the inside edge and tip about one-quarter inch thick where the soap is dispensed for hand washing. Further observation revealed S11 removed the gloves and applied another pair of gloves without washing her hands. S11was observed going to stir some onions cooking on the grill when she was stopped by the surveyor. S11 denied her hands were dirty. S11 indicated that she removed the dirty pair of gloves and applied a clean pair of gloves. S8 indicated S11's hands were dirty. S8 further indicated S11 should have washed her hands prior to applying another set of gloves.

During another observation of the kitchen on 8/3/10 at 11/17am, S24, Cook was observed in the kitchen preparation area when she coughed into her right hand then she wiped her nose with the same hand. S24 was observed not washing her hands after she coughed and wiped her nose in the food preparation area. She was further observed exiting the kitchen area through the snack bar area when she pushed the folded gates out of her way with the right hand that she had coughed and wiped her nose with. S24 was interviewed at this time. She indicated that she knew her hands were dirty. She stated that she was going to clean her hands on the way out of the kitchen. S8, Dietary Director agreed S24, Cook should not have left the kitchen area without washing her hands.

4) Food Temperatures:

An observation of the serving line food on 8/2/10 at 10:50am with S8 revealed the regular seasoned mashed potatoes had a temperature of 130 degrees Fahrenheit and the chopped meats had a temperature of 119 degrees Fahrenheit. During this same observation, S8 indicated the serving line food temperatures were to be at 140 degrees Fahrenheit. S8 further indicated the mashed potatoes and chopped meats were less than 140 degrees Fahrenheit.

A sampled food tray was tested on 8/3/10 at 11:35am by S8, Dietary Director. The test tray results are as follows: the barbecue regular seasoned chicken had a temperature of 139 degrees Fahrenheit, the baked beans had a temperature of 119 degrees Fahrenheit, and the cornbread had a temperature of 120 degrees Fahrenheit. During this same observation, S8 indicated that the food temperatures should be at 140 degrees Fahrenheit or above. S8 further indicated that the food temperatures of the chicken, baked beans and corn bread were less than 140 degrees Fahrenheit.

The policy titled, "Dress Code", Number 11.2, effective date, August 16, 2007, reviewed date of 2/22/10, with no revised date, presented as current "Kitchen Dress Code" policy, was reviewed and read in part, "...Dietary Employee Dress Code Standards: ...Hair protected/All hair under hair net...".

Review of the policy titled, "Dishwashing Procedures", Number 10.1, effective date of January 17, 2002, reviewed date of 2/22/10, with no revised date, presented as the current "Dishwasher's Procedures for temperature regulations", read, "Dish machine is preset with a wash temp. (Temperature) and rinse temp. of 125 (degrees) F (Fahrenheit)".

The policy titled, " Operation, Maintenance, Cleaning of Equipment " , Number 28.1, effective date of January 17, 2001, reviewed date of 1/17/01, revised dates from 1/15/09 to 2/17/09, presented as current policy was reviewed and read as follows, " Toasters- should be cleaned outside after each use. Remove the crumb trays daily or after each meal. " .

Review of the policy titled, ""HandWashing", with no Number, effective dates from 2/25/10 through 3/23/10, reviewed date of 2/16/04, revised dates from 1/15/09 to 2/17/09, presented as the current " Hand Washing " policy revealed in part, " How frequently should the hands be washed? At the very minimum, before beginning work, and in between contact with patients and/or equipment. " .

The policy titled, "Environmental Sanitation" with no Number, effective dates from 2/25/10 through 3/23/10, reviewed date of 2/16/04, revised dates from 1/15/09 to 2/17/09, presented as the current " Hand Washing " policy was revied and read in part, " Soiled equipment shall not be handled or stored in the same area as clean items. " .

Review of the policy titled, " Departmental Guidelines-Dietary " , Number 12.0, effective date of February 14, 2004, with no reviewed or revised dates, presented as the current " Dietary Guidelines " policy read in part, " ...Responsibilities:
A. FOOD SERVICE SUPERVISOR-
A. Evaluate cleanliness and food-handling practices.
B. Provide safe food service for patients.
C. Ensure proper maintenance and operation of equipment ....
B. General
b. Provide for the proper receiving and storage of all food supplies.
e. Maintain ice machine in a clean and sanitary condition.
PERSONNEL
A. Health
A. Health policies shall be in compliance with federal, state, and local laws.
C. Personal Hygiene
3. A hair net that covers all the hair must be worn and hair should be off collar.
8. Hands shall be washed with soap and water before beginning each work day and whenever they become dirty, before handling foods, after handling raw foods, after coughing, sneezing.
ENVIRONMENT
C. Housekeeping
3. All work surfaces, and equipment shall be cleaned and sanitized after each use.
FOOD
B. Preparation and Service
1. Hands shall be washed using germicidal soap immediately before food preparation and food service.
6. Coughing and sneezing shall be kept away from the preparation and serving.
EQUIPMENT
C. All food grinders, & etc. shall be cleaned, sanitized, dried and reassembled after each use.
D. Dishwasher
2. The inside shall be washed out after each use and the door left open to air dry the inside.
4. The dishwasher shall maintain a minimum water temperature of 120 degrees F.
G. Steam Table
1. Shall be able to maintain hot foods at temperatures of 140 degrees F, or above.
3. Must be kept clean and sanitary condition through daily cleaning.
H. Ice Machine
1. The outside of the ice machine shall be cleaned and sanitized daily ... " .

Based on record review and interview, the hospital failed to ensure the contracted RHIA (registered health information administrator) followed contract requirements of onsite visits at least 2 times a year by having 1 visit per year for the last 2 years which resulted in history and physicals (H&Ps) being tracked for dictation time rather than transcription time which allowed H&Ps to not be in the patient's record within 24 hours of admit, have verbal order physician signatures being tracked for signature only and not checking that a date and time of signature were included, and having medical staff bylaws identifying delinquent charts at greater than 30 days after having been placed in the physician's box. Findings:

Review of the "Health Information Management Services Agreement" revealed an agreement was entered into with Hospital B on 04/01/06 and remains current. Further review of the agreement revealed, in part, "...Hospital B shall make available to the following services: A. Transcription Services B. Coding Services C. Medical Records Consulting Services ... Medical Records Consulting Services ... Hospital B ' s medical records consultative services shall include: (i) consultation with Affiliates (surveyed hospital designated in agreement as Affiliate) Director of Medical Records or his/her designee regarding federal, state, and local regulations; (ii) provide documentation of services performed, findings and recommendations; ... (iv) verify that the system is reviewed and revised as needed; ... (vii) The Hospital B medical records consultant shall be either a registered health information record administrator or an accredited record technician ... (viii) The consultant ' s primary responsibility is to evaluate the ability and efficiency of the medical record personnel at Affiliate and to assist in correcting any deficiencies found; and (ix) Hospital B ' s designated visits shall occur not less than bi-annually and provide written reports of the findings and recommended actions to Affiliate ' s Chief Executive Officer ...".

Review of the "Biannual Status Report" of the Health Information Management Department revealed visits were made on 12/30/08 and 12/21/09. There was no documented evidence of bi-annual visits by the contracted RHIA for 2 years as required by the service agreement.

Review of the report submitted by Contracted RHIA S22 for 12/30/08 revealed Medical Records Supervisor S20 had indicated that the hospital was in compliance with verbal orders but the timing of the orders was still an issue. Further review revealed S20 indicated the hospital was in compliance with H&Ps. Further review revealed no documented evidence of a report regarding the percentage of delinquent medical records. Further review revealed the "next scheduled site visit by Hospital B will be in May 2009".

Review of the report submitted by Contracted RHIA S22 for 12/21/09 revealed no documented evidence of information regarding verbal orders, H&Ps, and delinquent medical record percentages. Further review revealed the "next scheduled site visit will be in June 2010".

In a face-to-face interview on 08/04/10 at 2:30pm, Medical Records Supervisor S20 indicated contracted RHIA S22 did a site visit 2 times a year. She further indicated S22 did a HIPAA (health information portability act) walk-through while on-site. She further indicated S22 did not review any hospital or patient records while on-site. When asked by the surveyor for the documentation from RHIA S22's twice a year visits, S20 presented documentation of 2 visits, one for 2008 and one for 2009. She confirmed S22 did not visit twice a year for the last 2 years. Medical Records Supervisor S20 indicated the hospital's policy considered a medical record to be delinquent 30 business days after it had been routed to the physician's box. She further indicated that it took an average of 1 week from discharge of the patient for medical record personnel to get the chart to the physician ' s box. When asked by the surveyor if she knew that the licensing regulations considered a medical record to be delinquent 30 days from discharge, S20 answered no. When asked by the surveyor what quality indicators were being tracked by the medical record department, S20 indicated they tracked: 1) H&Ps dictated in 24 hours of admit; 2) verbal orders signed by the physician within 10 days of giving the order (S20 indicated they checked to be sure it was signed, but did not look to see if the signature included a date and time when the physician signed the order); and 3) physician orders were dated and timed.

In a face-to-face interview on 08/04/10 at 3:00pm, Administrator S1 confirmed that the hospital's bylaws considered a medical record to be considered delinquent 30 business days after it was routed to the physician's box. He could offer no explanation for the contracted RHIA not performing site visits at least 2 times a year as required by the service agreement with Hospital B.

In a telephone interview on 08/04/10 at 3:20pm, Contracted RHIA S22 confirmed that she had not done site visits to the medical record department as required by the service agreement. She could offer no explanation for this not being done. She further confirmed that she did not perform any chart reviews while on-site. When informed of the surveyor ' s findings regarding H&Ps being transcribed more than 24 hours after admit (which meant the H&P was not on the record within 24 hours of admit), the delinquent chart policy, and physician verbal orders not being timed and dated when signed, S22 indicated she was not aware of the hospital's policy for delinquent medical records, that the Medical Records Supervisor was only checking for verbal order signatures by the physician and not assuring it was timed and dated when signed, and tracking of transcription rather than dictation was being done. She could offer no explanation for these findings having not been identified during her site visits.

Review of the hospital's Medical Staff Bylaws, last reviewed 02/24/10 and submitted by Director of Nursing S3 as the current bylaws, revealed, in part, "...Each medical record shall be completed within 30 working days after being routed to the physician's box or the record becomes delinquent ...".

Based on record review and interviews, the hospital failed to: 1) ensure contracted nursing personnel were oriented, supervised, and evaluated by a CAH (critical access hospital)-employed Registered Nurse (RN) for 3 of 3 contracted psychiatric nursing personnel reviewed from a total of 20 contracted nursing personnel (S4, S14, S19) and 2) ensure the hospital policy was followed that required licensed nursing employees to have current certification in CPR (cardiopulmonary resuscitation) by having 1 of 3 licensed nurses reviewed for CPR certification with an expired CPR certification (S14). Findings:

1) Contract employees oriented, supervised, and evaluated by CAH-employed RN:

Review of Psychiatric Director of Nursing (DON) S4's personnel file revealed her "RN Competency Skills Checklist" for 06/09/09, 03/18/08, and 03/06/07 were signed by S29, RN from Hospital A, as the evaluator. Review of S4's " Performance Appraisal/Competence Assessment" revealed it was completed and signed by S30, Chief Executive Officer of Hospital A on 07/21/10. There was no documented evidence that S4 had been oriented and evaluated by a CAH-employed RN.
Review of RN S14's personnel file revealed his "RN Competency Skills Checklist" for 07/06/08 was signed by Psychiatric DON S4 as the evaluator. Review of S14's "Performance Evaluation/Skills Assessment" revealed Psychiatric DON S4 performed the evaluation on 06/26/10. Further review revealed no documented evidence that S14 had been oriented and evaluated by a CAH-employed RN.

Review of Mental Health Technician (MHT) S19's personnel file revealed her orientations performed on 06/09/09, 03/18/08, and 06/30/06 were performed by Psychiatric DON S4. Further review revealed S19's MHT competency was assessed by Psychiatric DON S4 on 06/09/09, 03/18/08, 03/08/07, and 06/30/06. Review of the "Performance Evaluation/Skills Assessment" performed on 03/20/09 revealed Psychiatric DON S4 had performed the evaluation. Review of S19's entire personnel file revealed no documented evidence S19 had been oriented, supervised, and evaluated by a CAH-employed RN.

In a face-to-face interview on 08/03/10 at 2:45pm, Psychiatric DON S4 confirmed that the CAH DON was not responsible for the supervision of the behavioral health unit staff and had not performed orientation, competency assessments, and evaluations of the contracted employees of the behavioral health unit.

In a face-to-face interview on 08/03/10 at 3:00pm, DON S3 confirmed that her staff on the acute unit did not have a role in the supervision of the contracted behavioral health unit. DON S3 further confirmed that she was responsible for the acute unit and the emergency room and had no responsibility for the contracted psychiatric unit.

Review of the hospital's Organizational Chart, presented by Administrator S1 as the current organizational chart for the hospital, revealed the DON was responsible for the Behavioral Health Unit.

Review of the hospital policy titled, "Introduction", effective 01/08/08 and presented by DON S3 as their current policy for the nursing service organization, revealed, in part, "...4. Organization: The Nursing Service Department comprises the nursing service office and nursing sections. The nursing sections are: the Emergency Room, Acute Care, Swingbed, Surgery and Recovery ...". Review of the entire policy revealed no documented evidence that the behavioral health unit was a part of the nursing service department.

2) CPR Certification:
Review of RN S14's personnel file revealed his CPR certification expired 07/31/10. There was no documented evidence of a current CPR certification for S14.

In a face-to-face interview on 08/04/10 at 8:45am, Psychiatric DON S4 confirmed RN S14's CPR was expired.

Review of the hospital policy titled "Orientation And Training", with no documented evidence of an effective date and presented by Psychiatric DON S4 as their current policy for CPR certification, revealed, in part, "...Licensed nursing employees must maintain CPR ...".

Based on record review and interview, the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the care of the patient by failing to assess a patient after a change in condition for 3 of 7 sampled psychiatric patients reviewed for a change in condition from a total of 26 sampled patients (#8, #10, #24). Findings:

Patient #8
Review of Patient #8's medical record revealed he was admitted on 07/24/10 with a diagnosis of Major Depression. Further review revealed his legal status was PEC (physician emergency certificate) on 07/23/10 due to suicidal and dangerous to self and CEC (coroner's emergency certificate) on 07/26/10 due to dangerous to self and unable to seek voluntary admission.
Review of Patient #8's medical record revealed documentation of a late entry by RN S14 on 07/31/10 at 2105 (9:05pm) that Patient #8 fell in the day room, was dizzy and disoriented with a blood pressure of 74/46. Further review revealed Patient #8 was brought to the emergency room.
Review of Patient #8's "Emergency Physician Record" revealed he was treated for hypotension.
Review of the entire medical record revealed no documented evidence of an order to take Patient #8 to the emergency room (ER) nor orders upon his return from ER.
Review of the "Progress Notes" dated 07/31/10 at 2315 (11:15pm) documented by RN S14 revealed Patient #8 returned to the psychiatric unit from the emergency room at 11:15pm. Further review revealed no documented evidence of an assessment of vital signs, system review, and level of pain upon return from emergency room and throughout the remainder of the night shift.
In a face-to-face interview on 08/03/10 at 8:05am, RN S14 indicated that what he documented "wasn't accurate". He further indicated Patient #8 did not fall but was helped to a chair by other patients when he became weak and dizzy. S14 could offer no explanation for not documenting orders by Nurse Practitioner S27 to send to ER, not having physician orders upon return from ER, and no patient assessment including vital signs upon return from ER and throughout the night.

Patient #10
Review of Patient #10's medical record revealed he was admitted on 08/01/10 with the diagnosis of Bipolar Disorder. Review of his PEC on 07/30/10 revealed he had suicidal thoughts. Review of his CEC on 08/02/10 revealed Patient #10 was having thoughts of buying a gun and ending his life.
Review of Patient #10's "Social Services Progress Notes" documented on 08/02/10 at 10:15am by Licensed Clinical Social Worker (LCSW) S39 revealed "met briefly w/pt (with patient) for psychosocial assessment. He abruptly left session after he asked about subsidized housing and was told he'd have to get his name on a waiting list. He walked out saying "This is s---! I wanna just shoot myself!".
Review of the entire medical record revealed no documented evidence LCSW S39 reported Patient #10's suicidal statement to a RN who subsequently assessed him with a change in condition.

Patient #24
Review of Patient #24's medical record revealed she was admitted on 05/20/10 with the diagnosis of Schizophrenia.
Review of the "Psychosocial Assessment" completed on 05/21/10 by LPC (licensed professional counselor) S16 revealed, in part,
" ...Current Suicidal Ideation and/or Plans? SI (suicidal ideations) with plans to cut wrists at 5 PM or take pills ...".
Review of the entire medical record revealed no documented evidence LPC S16 reported Patient #24's suicidal plans to the RN who would subsequently assess the patient for a change in condition.

In a face-to-face interview on 08/03/10 at 2:45pm, Psychiatric Director of Nursing indicated the above-documented reports of thoughts of or statements of plans for suicide should have been reported to a RN who should have assessed the patients with the change in condition.

Review of the hospital policy titled "Assessments Of Patients", with no documented evidence of the date of effectiveness or approval by the governing body and submitted by Psychiatric Director of Nursing S4 as their current policy on reassessment with a change in condition, revealed, in part, "...Patients are reassessed throughout the care process. A qualified registered nurse conducts a reassessment of the patient ' s condition every eight hours. A reassessment is also indicated at any time for any significant change in the patient condition, diagnosis, and/or response to care provided ...".

Based on record review and interviews, the hospital failed to ensure all drugs administered were in accordance with written and signed orders by failing to: 1) ensure all drug orders were timed, dated, and authenticated by the physician for 1 of 26 sampled records reviewed for drug orders to be timed, dated, and authenticated (#8); 2) ensure read back verification of verbal orders received by the nurse for 7 of 26 sampled records reviewed for read back verification (#8, #9, #10, #11, #12, #13, #24); and 3) ensure all elements required in any verbal medication order was included by not having the name of the drug, the purpose or indication for use, and the route to be used for 3 of 26 sampled records reviewed for complete medication orders (#8, #9, #10). Findings:

1) Drug orders timed, dated, and authenticated:
Patient #8
Review of Patient #8's "Medication Reconciliation/Verification Form" dated 07/24/10 revealed no documented evidence of the time the order was received by Registered Nurse (RN) S31.

In a face-to-face interview on 08/04/10 at 8:45am, Psychiatric Director of Nursing (DON) confirmed there was no date the medication reconciliation order was received.

Review of the hospital policy titled "Requirements For Medication Orders", effective 01/08/08 and presented as the current medication policy by DON S3, revealed, in part, "1. Written Orders a) Must specify date and time of order ...".

Review of the Medical Staff Bylaws, last reviewed by the governing body on 02/24/10 and presented by DON S3 as the current Medical Staff Bylaws, revealed, in part, "...All clinical entries in the patient's medical record shall be legible and accurately dated, timed and authenticated. ... The practitioner must separately date and time his/her authenticating an entry even though there may already be a date and time on the document ...".

2) Read back verification:
Patient #8
Review of Patient #8's medical record revealed the "B.H.U. (Behavioral Health Unit) - Physician Orders Medication Reconciliation/Verification Form" had no documented evidence of a read back verification when the order was received by RN S31. Further review revealed verbal orders received on 07/29/10 at 1:40am and 08/03/10 at 2:00am by RN S31 had no documented evidence of a read back verification when the order was received.

Patient #9
Review of Patient #9's medical record revealed the "B.H.U.- Physician Orders Medication Reconciliation/Verification Form" had no documented evidence of a read back verification when the order was received by RN S34. Review of the "Physician's Admission Orders" dated 07/23/10 at 4:45pm revealed no documented evidence of a read verification when the verbal order was received by LPN (licensed practical nurse) S33. Further review revealed a verbal order received by LPN S32 on 07/24/10 at 8:00am had no documented evidence of a read back verification.

Patient #10
Review of Patient #10's physicians' orders revealed no documented evidence of read back verification for verbal orders received on 08/01/10 at 4:00pm by RN S35 and on 08/01/10 at 11:00pm by RN 14.

Patient #11
Review of Patient #11's "B.H.U.- Physician Orders Medication Reconciliation/Verification Form" (no documented evidence of the date and time the order was received) and "Physician's Admission Orders" dated 07/25/10 at 8:15pm revealed no documented evidence of a read verification when the verbal order was received by RN S14.

Patient #12
Review of Patient #12's "B.H.U.- Physician Orders Medication Reconciliation/Verification Form" and "Physician's Admission Orders" dated 07/28/10 at 6:15pm revealed no documented evidence of a read verification when the verbal order was received by LPN S33.

Patient #13
Review of Patient #13's "B.H.U.- Physician Orders Medication Reconciliation/Verification Form" for 07/29/10 at 7:15pm revealed no documented evidence of a read back verification when the order was received by RN S34. Review of the "Physician's Admission Orders" dated 07/29/10 at 7:15pm revealed no documented evidence of a read verification when the verbal order was received by LPN S33.

Patient #24
Review of Patient #24's "B.H.U.- Physician Orders Medication Reconciliation/Verification Form" for 05/20/10 at 5:00pm revealed no documented evidence of a read back verification when the order was received by RN S37. Review of the "Physician's Admission Orders" dated 05/20/10 at 5:00pm revealed no documented evidence of a read verification when the verbal order was received by LPN S36. Further review revealed a verbal order received 05/30/10 at 6:30am by RN S14 had no documented evidence of a read back verification.

In a face-to-face interview on 08/04/10 at 8:45am, Psychiatric DON S4 could offer no explanation for the nurses not confirming physician orders with a read back verification.

Review of the Medical Staff Bylaws, last reviewed by the governing body on 02/24/10 and presented by DON S3 as the current Medical Staff Bylaws, revealed, in part, "...All orders for treatment shall be documented in the chart ... After receiving the order, the licensed person will repeat the order to the prescribing physician for clarification. The licensed person will then transcribe, sign, date, and time the dictated order on the perspective patient's physician order sheet ...".

3)All elements of a medication order present:
Patient #8
Review of Patient #8's "B.H.U.- Physician Orders Medication Reconciliation/Verification Form" revealed an order for Lortab 5/500 mg (milligrams) 1 tablet by mouth three times a day prn (as needed). Further review revealed no documented evidence of the indication for use of Lortab.

Patient #9
Review of Patient #9's "Physician's Admission Orders" dated 07/23/10 at 4:45pm revealed an order for "CBG (capillary blood glucose) per S/S (sliding scale: 201-250=5u's (units); 251-300=7u's; 301-350=10u's; > (greater than) 350=15u's & (and) call MD (medical doctor)" . Further review revealed no documented evidence of the type of insulin to be used nor the route of administration.

Patient #10
Review of Patient #10's physician orders revealed an order on 08/21/10 at 11:55am for Advil 200 mg by mouth TID (three times a day) prn. Further review revealed no documented evidence of the indication for use of Advil.

In a face-to-face interview on 08/04/10 at 8:45am, Psychiatric DON S4 confirmed the medications without indication for use and the lack of the name and route for insulin administration. She indicated there should have been clarification orders to correct the incomplete medication orders.

Review of the hospital policy titled "Requirements For Medication Orders", effective 01/08/08 and submitted by DON S3 as the hospital's current policy for medication administration, revealed, in part, "...must specify drug, dosage, route, time intervals (and for PRN medication, the reason for administration) ...".

Based on record review and interview, the hospital failed to ensure a nursing care plan was developed and kept current for each patient by: 1) having care plans that were not individualized and included measurable goals for 4 of 7 sampled psychiatric patients from a total sample of 26 patients (#8, #9, #10, #11) and 2) failing to update a care plan with a change in condition for 1 of 3 psychiatric patients with a change in condition from a total of 7 psychiatric patients reviewed from a total of 26 sampled patients (#8). Findings:

1) Individualized care plans with measurable goals:
Review of the care plans for Patients #8, #9, #10, and #11 revealed they all had the same information in check-box format with no patient individualization concerning short term and long term goals. Further review revealed all patients would be monitored for the same behaviors and the same signs and symptoms.

In a face-to-face interview on 08/03/10 at 2:45pm, Psychiatric Director of Nursing (DON) S4 indicated the care plans were "cookie cutter" design. She confirmed they were not individualized, and the goals were not measurable.

Review of the hospital policy titled "Treatment Plans", with no documented evidence of an effective date and approval by the governing body, revealed, in part, "...Each patient will have an individualized inter-disciplinary treatment plan ... The treatment plan will coordinate treatment interventions and outline individualized specific long-term goals to evaluate therapeutic progress. The plan will revised throughout the patient's hospitalization to reflect progress towards the treatment goals. ...".

2) Updated care plan with a change in condition:
Patient #8
Review of Patient #8's medical record revealed he was admitted on 07/24/10 with a diagnosis of Major Depression. Review of Patient #8's medical record revealed he had an episode of hypotension that required emergency room treatment. Further review revealed Patient #8's treatment was not updated with this change in condition.

In a face-to-face interview on 08/03/10 at 2:45pm, Psychiatric Director of Nursing confirmed the care plan for Patient #8 was not updated to include the problem of hypotension.

Review of the hospital policy titled "Treatment Plans", with no documented evidence of an effective date and approval by the governing body, revealed, in part, "...Each patient will have an individualized inter-disciplinary treatment plan ... The treatment plan will coordinate treatment interventions and outline individualized specific long-term goals to evaluate therapeutic progress. The plan will be revised throughout the patient ' s hospitalization to reflect progress towards the treatment goals. ...".

Based on record review and interview, the hospital failed to ensure all medical record entries were timed, dated, and authenticated for 6 of 26 sampled patient records (#8, #9, #10, #11, #12, #24). Findings:

Review of the "Psychosocial Assessment" and the "Activity And Skills Assessment" for Patients #8, #9, and #12 revealed no documented evidence of the time the assessments were performed.

Review of the "Psychosocial Assessment" for Patients #11 and #24 revealed no documented evidence of the time the assessments were performed.

Review of the "Activity And Skills Assessment" for Patient #10 revealed no documented evidence of the time the assessment was performed.

In a face-to-face interview on 08/02/10 at 3:15pm, Psychiatric Director of Nursing confirmed that the psychosocial and activity assessments should be timed when they are done.

Review of the Medical Staff Bylaws, approved 02/24/10 by the governing body and submitted by Director of Nursing S3 as the current medical staff bylaws, revealed, in part, "...All clinical entries in the patient ' s medical record shall be legible and accurately dated, timed, and authenticated ...".

Based on record review and interview, the hospital failed to ensure the annual evaluation included the number of patients served and the volume of services. Findings:

Review of the hospital's Quality Improvement and Performance Improvement (QAPI) Plan and the "Quality Improvement Program Annual Evaluation For Year 2009", signed by Administrator S1 on 01/25/10, revealed no documented evidence the evaluation included the number of patients served and the volume of services provided.

In a face-to-face interview on 08/05/10 at 9:45am, Director of Nursing S3 indicated she was responsible for QAPI. She further indicated she compiles the data from the quarterly quality indicators for Administrator S1 to complete the annual evaluation. She confirmed the evaluation did not include the number of patients served and the volume of services provided.

Review of the hospital's policy titled "Quality Improvement (QI) & (and) Performance Improvement Plan", effective 01/12/10 and submitted by DON S3 as the hospital's current policy for QAPI, revealed, in part, "...Annual Review Of Performance Improvement & Quality Assessment Plan The Performance Improvement and Quality Assessment Plan will be reviewed and revised annually by (name of hospital)QI Committee and Administrator. The structure, functions, and methods of the PI and quality assessment will be evaluated to assure that the program is achieving objectives, is effective, cost-efficient and consistent with the mission, vision, and goals ... The plan will also be appraised for compliance with all regulatory agencies, CMS (Centers for Medicare and Medicaid Services) standards, as well as other external requirements ...".

Based on record review and interview, the hospital failed to ensure the annual evaluation included a review of a sample of both active and closed medical records. Findings:

Review of the "Quality Improvement Program Annual Evaluation For Year 2009", signed by Administrator S1 on 01/25/10, revealed no documented evidence that a review of patient medical records was performed. Further review revealed the evaluation included a "yes" answer to the following questions: 1) have important and meaningful problems been identified; 2) have identified problems been assessed to determine cause and scope; 3) are predetermine, clinically valid criteria used to identify and assess problems; 4) are the appropriate individuals responsible for implementing action; 5) have problems been monitored to determine if they are resolved or reduced to an acceptable level; and 6) are problems monitored by appropriate individuals.

In a face-to-face interview on 08/05/10 at 9:45am, Director of Nursing S3 indicated she was responsible for QAPI. She further indicated she compiles the data from the quarterly quality indicators for Administrator S1 to complete the annual evaluation. She confirmed the annual evaluation did not include a review of any patient medical records.

Review of the hospital's policy titled "Quality Improvement (QI) & (and) Performance Improvement Plan", effective 01/12/10 and submitted by DON S3 as the hospital ' s current policy for QAPI, revealed, in part, "...Annual Review Of Performance Improvement & Quality Assessment Plan The Performance Improvement and Quality Assessment Plan will be reviewed and revised annually by (name of hospital)QI Committee and Administrator. The structure, functions, and methods of the PI and quality assessment will be evaluated to assure that the program is achieving objectives, is effective, cost-efficient and consistent with the mission, vision, and goals ... The plan will also be appraised for compliance with all regulatory agencies, CMS (Centers for Medicare and Medicaid Services) standards, as well as other external requirements ...".

Based on record review and interview, the hospital failed to ensure the quality assurance program evaluated the quality and effectiveness of the diagnosis and treatment furnished in the hospital by not ensuring problem prevention, identification, analysis, identification of corrective action, and evaluation and monitoring of corrective actions was being performed. Findings:

Review of the Quality Improvement Committee Minutes for the third and fourth quarter of 2009 and the first and second quarter for 2010 revealed the quality indicator thresholds for Medical Records and Nursing Service were not met. Further review revealed no documented evidence of action taken to correct the deficiencies.

In a face-to-face interview on 08/04/10 at 2:30pm, Medical Records Supervisor S20 indicated the quality indicators for the medical records department were: 1) history and physical (H&P) dictated in 24 hours; 2) verbal orders signed in 10 days; and 3) date and time included on all orders. She confirmed that she was checking that H&Ps were dictated in 24 hours, but she did not ensure the transcription was completed within 24 hours to assure the H&P was in the medical record within 24 hours. She further confirmed that she was only checking that physicians signed the verbal orders in 10 days, but she did not check to be sure the signatures included a date and time.

Review of the Quality Improvement Committee Minutes for the first quarter of 2010 revealed the nosocomial rate for the acute unit was 1% (per cent). Further review revealed there was no documented evidence of action to be taken. Review of the minutes for the second quarter of 2010 revealed the acute unit's nosocomial rate for 6%, and there was no documented evidence of action to be taken.

In a face-to-face interview on 08/05/10 at 9:10am, Infection Control Registered Nurse S17 confirmed she was the infection control nurse for the hospital. She indicated there was a physician-confirmed catheter-related urinary tract infection (UTI) in the first quarter of 2010 and 2 physician-confirmed catheter-related UTIs in the second quarter of 2010. She indicated she was monitoring the UTIs, but she had not investigated the 3 UTIs to determine if they were from the same unit or the same nurse had inserted the catheter. She further indicated she had not done any re-education regarding catheter insertion and catheter care as of the time of this interview. S17 confirmed she was not investigating, implementing corrective action, and monitoring and evaluating the effectiveness of the corrective action for UTIs .

In a face-to-face interview on 08/05/10 at 9:45am, Director of Nursing (DON) S3 confirmed that she was responsible for quality assurance activities at the hospital. When informed of the information presented by Medical Records Supervisor S20, DON S3 confirmed that the Medical Record Department quality data collected and reported was inaccurate. After reviewing the information presented by Infection Control Registered Nurse S17 and information documented in the quarterly meeting minutes, DON S3 confirmed that investigation, analysis, implementing corrective action, and evaluating and monitoring the effectiveness of corrective actions were not being done. S3 could offer no explanation for these actions not being performed.

Review of the hospital's policy titled "Quality Improvement (QI) & (and) Performance Improvement Plan", effective 01/12/10 and submitted by DON S3 as the hospital's current policy for QAPI, revealed, in part, "...Clinical (process and outcomes) indicators will be developed, monitored, analyzed and reported across the continuum of the health care organization. The Plan, Do, Check and Act (PDCA) process will be used as a guideline to demonstrate a theoretical base for the process that we employ. ...The Administrator has the authority and responsibility for all organizational performance. The Administrator is responsible for implementation and administration of the QI/PI (quality improvement/performance improvement) Plan ...".

Based on record review and interview, the hospital failed to ensure the behavioral health unit followed hospital policy for utilization review (UR) by: 1) having no documented evidence of a committee consisting of a registered nurse, social worker, activity therapist, and psychiatrist, 2) having no documented evidence of the representation of the closed records reviewed, 3) not analyzing data to compile statistics along with a corrective action plan for indicators falling below the acceptable threshold, and 4) not reporting statistical data to the Quality Assurance Committee. Findings:

Review of the data presented by Psychiatric Director of Nursing (DON) S4 as the psychiatric department's UR revealed a sheet with the heading "Quality Assurance". Further review revealed the services reviewed were nursing, activity therapy, social services, and physician services. There was no documented evidence of the means used to select the patient's records that were reviewed.
Review of the Nursing Services section of the review revealed the following items were audited: all consents are properly witnessed, timed, and dated; all orders are dated, timed and signed off by a nurse; the initial treatment plan initiated within 24 hours and reflects identified problems from the nursing assessment; routine medications are administered as ordered and results and justification are documented; prn (as needed) medications are administered as ordered and results and justifications are documented; b/p (blood pressure) and/or pulse documented on MAR (medication administration record) prior to administering antihypertensive or cardiac glycoside, antidysrythmic, or inotropic medications; vital signs reviewed by RN (registered nurse) every shift and documentation of physician notified of significant changes, including weekly weights; ongoing medical problems and new medical problems, as they occur, are addressed on the Treatment Plan; Treatment plans indicate ongoing review and re-evaluation of problems and goals; discharge planning is noted during the Treatment Plan development; and Ticket To Ride form completed on all transfers and discharges.

In a face-to-face interview on 08/04/10 at 10:05am, Psychiatric DON S4 indicated there was no UR committee, and thus there have been no meetings. She further indicated she did the chart reviews, but the data collected from patient record reviews was not compiled and tracked to determine if there was an identified problem with corrective action planned when indicated. She confirmed that there was no reporting of UR data to the hospital's QA/UR (quality assurance/utilization review) Committee. After review of the hospital's UR policy, S4 confirmed that she was not following hospital policy for UR.

Review of the hospital's policy titled "Utilization Review", with no documented evidence of the effective date or approval by the governing body, revealed, in part, "...The Utilization Review of Hospital A focuses on quality management of patient care. Utilization control methods are used to examine the appropriateness of the hospitalization, appropriateness of services provided or those not provided and evidence that discharge planning is ongoing from the time of admission. Procedure: Retrospective Review - Retrospective review focuses on the care or service after it has been provided. The committee is chaired and appointed by the Unit Program Director. 1) Retrospective reviews are performed by a committee consisting of a registered nurse, social worker, activity therapist and psychiatrist. 2) The Committee shall review on a quarterly basis a 20% (per cent) sample representation of those closed records of the previous quarter. 3) The representation will include: a) All days greater than 45 days b) All stays less than 2 days c) Those readmitted with a discharge within 72 hours prior d) All AMA's (against medical advice) e) All seclusions and restraints, and f) All those with a documented fall ... 7) The statistics shall be compiled along with a plan of corrective action for those indicators falling below the acceptable threshold. 8) The above information will be reported and turned in to the Hospital QA/UR (quality assurance/utilization review) Committee for its review. Minutes of the Hospital Committee shall be maintained and reflect this information".

Based on record review and interview, the hospital failed to ensure psychiatric evaluations were performed by the psychiatrist within 60 hours of admission for 2 of 6 psychiatric patients reviewed for psychiatric evaluations from a total of 7 sampled psychiatric patients (#8, #9). Findings:

Review of Patient #8's medical record revealed he was admitted on 07/24/10 at 1:00am. Review of Patient #8's "Psychiatric Evaluation" revealed it was performed by Physician S38 on 07/27/10 at 5:15pm, more than 60 hours after admission.

Review of Patient #9's medical record revealed he was admitted on 07/23/10 at 4:45pm. Review of Patient #9's "Psychiatric Evaluation" revealed it was performed on 07/27/10 with no documented evidence of the time it was performed by Physician S38. This was more than 60 hours after admission.

In a telephone interview on 08/04/10 at 1:10pm, Psychiatric Medical Director S18 indicated that most of the psychiatric evaluations were done within the 60 hour time frame unless circumstances existed that were beyond his control. When told that 2 of 6 patient psychiatric evaluations were not performed within 60 hours of admission, S18 could offer no explanation, other than sometimes it may be late since he also covered other hospitals.

Review of the hospital policy titled "Psychiatric Evaluation/Psychiatrist Admission Note", with no documented evidence of the effective date or the date approved by the governing body and submitted by Psychiatric Director of Nursing as the current policy for psychiatric evaluations, revealed, in part, "...An admit note, written by the admitting psychiatrist within sixty (60) hours of pre-approved patient ' s admission or at initial assessment ...".

Based on interview, the hospital failed to ensure the Director of inpatient psychiatric services evaluated the quality and appropriateness of the services provided by the medical staff. Findings:

In a telephone interview on 08/04/10 at 1:10pm, Medical Director of the Psychiatric Unit S18 confirmed he did not perform peer review or quality review of the medical staff providing services to the psychiatric patients.