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Based on a review of clinical records, interviews with both administrative and clinical staff, the govererning failed to ensure care and supervision was provided to patients, and medications were administered as ordered. Refer to details under the Condition of Participation of nursing services A385. The governing body failed to assure there was an active grievance program which resulted in investigations, changes as necessary, and resolution information being given to patients (refer to A120 and 123). The governing body failed to have an active, hospital wide quality assurance program to ensure there was quality care to patients (refer to Condition of Participation at A263). The hospital failed to ensure there was an active utilization review department performing chart reviews. (refer to condition of Participation at A658)

Based on facility interviews and record review, the facility failed to provide interventions regarding grievances, verbal, and written complaints.

The findings included:

The grievance information request was included in the entrance conference conducted on 3/6/17 by the survey team. On 3/8/17, the Risk Manager (RM) presented an expandable file with grievance information and commented the grievance folder was "found" on a shelf in her office.
On 3/8/17 at 3:00 p.m., a record review of the grievance interventions and grievance logs was conducted after the grievance logs were located.

The grievance facility form entitled " ... Complaint Grievance Log" review revealed the forms lacked entries for the "Status", "Letter", and "Resolved" sections of the form.

A facility form contained a hospital Logo and a numeric key to indicate the type of "Complaint" and included a "Status Legend".
The "Status Legend" contains an "S" for Substantiated, "U" for unsubstantiated and a "P" for partially substantiated.

The 2016 facility grievances and complaint form review included:

On 4/11/16, 4/12/16, and 4/13/16 Patient #67 had multiple complaints and grievances with no documentation of the status, interventions, or follow-up.
The complaint/grievance log for July 2016 contains 18 entries documented as "complaints". The documentation of the complaint "status" sections for each of the complaints contains "unknown" as an entry. The current RM did not comment on the follow-up for these entries.
On 8/2/16 Patient #66 had no documentation of status, interventions or follow-up.
On 8/8/16 Patient #65 had no documentation of status, interventions or follow-up.
On 10/14/16 Patient #68 had no documentation of status, interventions, or follow-up.

On 3/8/17 at 3:05 p.m., an interview and record review conducted with the RM revealed the following findings. A handwritten "Patient Concern/Grievance Notification" form dated 10/14/16 contains the signature of Patient #68's. The incident contained concerns regarding medication doses and staff conduct and communication. The disposition section was blank. On the same date of 10/14/16, Patient# 68 completed an additional grievance regarding privacy and confidentiality concerns regarding her chart information, commenting students entered her room and she observed the students in her chart. Another "Patient Concern/Grievance Notification" was without patient identifiers or disposition and contained a hand written entry of "HIPPA VIOLATION".

Review of the grievances and complaints for October, November, and December 2016 contained incomplete documentation of the follow up and status. The RM explained the information was difficult to locate and this is all that was available.
The RM explained she was a new hire at the facility in October 2016 and could not speak to incident occurring before her hire date. When asked about Patient #68, the RM explained the facility was a "hot mess" when she arrived. She continued to explain the facility risk management and quality programs require evaluations and interventions.
The RM explained the facility had experienced multiple surveys. The RM explained due multiple surveys, investigations or interventions regarding the risk management and quality programs, the grievance and complaints lacked follow-up. The RM commented "the processes" for indicators and interventions for trending or audits were not "in place" at the time of survey. The RM verified she completed staff education performed for immediate intervention, but the follow up to ensure effectiveness of the education intervention did not take place.

On 3/8/17 at 4:45 p.m., an interview conducted with the corporate director of Clinical Services (CDCS) included a review of the grievance findings. The CDCS explained the expectation was the grievance information would be complete with explanation of interventions, plans for resolutions, including correspondence and final status.
The CDCS explained the facility was without a risk manager and quality manager for a few months. She explained the facility assigned the infection control nurse the additional responsibilities of risk management and quality.
She explained the company did not intervene with assistance with the risk, quality, or infection control programs during the time the facility had not filled the position a for risk and quality manager.
The CDCS did comment she was aware the company had sent assistance to other facilities during periods of employee searches to insure program success, but this did not occur with this facility.

Based on staff interviews, and record review, the facility failed to provide interventions regarding grievances, verbal, and written complaints and failed to show a resolution in writing for the grievance.

The findings included:

The grievance information was requested during the entrance conference conducted on 3/6/17 by the survey team. On 3/8/17, the Risk Manager (RM) presented an expandable file with grievance information and commented the grievance folder was "found" on a shelf in her office.

On 3/8/17 at 3:00 p.m., a record review of the grievance interventions and grievance logs was conducted.

The complaint /grievance log review revealed the forms lacked entries for the "Status", "Letter" and "Resolved" sections of the form.
A facility form which contained a hospital Logo included a numeric key to indicate the type of "Complaint" and included a "Status Legend".
The "Status Legend" contains an "S" for substantiated, "U" for unsubstantiated and a "P" for partially substantiated.

The 2016 facility grievances/complaint forms review included:

Patient #67 had multiple complaint and grievances with no documentation of
any status,interventions, or follow-up. The complaints were dated 4/11, 4/12, 4/13/2016.

The complaint/grievance log for July 2016 contains 18 entries documented as "complaints". The documentation of the complaint "status" sections for each of the complaints contain "unknown" as an entry.
Patient #66 had no documentation of status, interventions or follow-up for a complaint on 8/2/16.
Patient #65 had no documentation of status, interventions or follow-up for a complaint on
8/8/16.
Patient #68 had no documentation of status, interventions or follow-up for a complaint on 10/14/16.

During an interview and record review with the RM conducted on 3/8/17 at 3:05 p.m., of the grievance logs and the facility form entitled "Patient Concern/Grievance Notification", a handwritten "Patient Concern/Grievance Notification" form dated 10/14/16 contained a signature with Patient #68's name. This incident contained concerns regarding medication doses and staff conduct and communication. The disposition section was blank. On the same date of 10/14/16, the same Patient# 68 completed an additional grievance regarding privacy and confidentiality concerns regarding her chart information, commenting students entered her room and she observed the students looking in her chart. Another "Patient Concern/Grievance Notification" was without patient identifier or disposition and contained a hand written entry "HIPPA VIOLATION".

The record review of grievances and complaints for October, November, and December 2016 contained incomplete documentation of follow up and status of complaints. The RM explained the information was difficult to locate and this is all that was available.

The RM explained she was a new hire at the facility in October 2016 and could not speak to incident occurring before her hire date. When asked about Patient #68, the RM explained the facility was a "hot mess" when she arrived. She continued to explain the facility risk management and quality programs require evaluations and interventions to improve the programs.

The RM explained due multiple surveys, investigations or interventions regarding the risk management and quality programs, the grievance and complaints lacked follow-up. The RM commented "the processes" for indicators and interventions for trending or audits were not "in place" at the time of survey. The RM verified she completed staff education performed for immediate intervention, but the follow up to insure effectiveness of the education intervention did not take place.

On 3/8/17 at 4:45 p.m., an interview conducted with the Corporate Director of Clinical Services (CDCS) included a review of the grievance findings. The CDCS explained the expectation is the grievance information would be complete with explanation of interventions, plans for resolutions, including correspondence and final status.
The CDCS explained the facility was without a risk manager and quality manager for a few months. She explained the facility assigned the infection control nurse the additional responsibilities of risk management and quality.
The CDCS explained the company did not intervene with assistance for the risk, quality, or infection control programs during the time the facility had not filled the position for risk and quality manager.
The CDCS did comment she was aware the company had sent assistance to other facilities during periods of employee searches to insure program success, but this did not occur with this facility.

Based on observation and staff interviews on 3/9/17, the facility failed to maintain electrical equipment and wiring in accordance with NFPA 70, The National Electric Code (N.E.C.), and NFPA 99 Health Care Facilities Code to provide a facility free from electrical hazards. Failure to maintain electrical devices, equipment, and wiring in accordance with the applicable standards can result in the hazards of electric shock, electrocution, energized equipment and fire resulting from electric sources.

The findings include:

During the tour of the facility's geriatric unit on 3/9/17 at 1:25 p.m. with the facility maintenance staff, the geriatric unit's population utilizes electrically operated hospital beds. Visual observations of these beds (patient care equipment), reveal the power cords had been modified by shortening them. This resulted in a two-foot power cord to provide the electrical connection in wall outlet for the beds in the Geriatric Unit.

On 3/9/17 at 1:25 p.m., the facility maintenance staff on 3/9/17 at 1:25 p.m. revealed he "had modified the power beds cords just enough to plug in and bed raised up or down". This supported the visual observation of that the cords to all the hospital beds in this unit had been shortened.

Based on a review of quality assurance minutes, governing body minutes, and interviews with both clinical staff, and administrative staff, the quality assurance committee is not being utilized to improve services by identification of opportunities for improvement, and the follow through to show consistent improvements. (see tag A283 for details) The programs failed to use incident reports to identify issues and interventions to improve activities. (see tag A286 for details) There were no established quality assurance projects established by the hospital for areas of improvement. (see A297 for details) The quality assurance program did not involved all departments of the hospital. (see A309 for details) The governing body did not provide sufficient resources to ensure the quality assurance program was viable, ongoing, and was involved in patient safety and prevention of errors throughout the hospital. (see A315)

On 3/8/2017 the Risk Manager, who also acts as the QAPI manager confirmed the facility experienced a period of time during which the facility lacked the direction of a Risk Manager or a Quality Manager.

On 3/8/2016 at 4:45 p.m., the CDCS explained the facility was without a risk manager and quality manager for a few months. The CDCS explained the facility assigned the infection control nurse the additional responsibilities of risk management and quality management.
The CDCS explained the company did not intervene with assistance with the risk or quality programs during the time the facility had not filled the positions. The CDCS said she was aware the company had sent assistance to other facilities during periods of employee searches to insure program success, but this did not occur with this facility.

A review of the grievance findings was conducted with the CDCS. She explained the expectation is the grievance information would be complete with explanation of interventions, plans for resolutions, including correspondence and final status

Based on facility interviews, and record review, the facility failed to provide interventions regarding grievances, verbal, and written complaints.

The findings included:

The grievance information request is included in the entrance conference conducted on 3/6/17 by the survey team. On 3/8/2017, the Risk Manager (RM) presented an expandable file with grievance information and commented the grievance folder was "found" on a shelf in her office.
A review conducted on 3/8/17 at 3:00 p.m. of the grievance interventions and grievance logs occurred once these were located.

The grievance facility form entitled " ... Complaint Grievance Log" review revealed the forms lacked entries for the "Status", "Letter" and "Resolved" form sections.
Another facility form contained a hospital Logo and a key to indicate the type of "Complaint" are indicated by numeric entry and included a "Status Legend".
The "Status Legend" contains an "S" for Substantiated, "U" for unsubstantiated and a "P" for partially substantiated.

The 2016 facility grievances and complaint forms review included:
4/11/16, 4/12/16, 4/13/16: Patient #67- multiple complaint and grievances- no documentation of status /interventions/follow-up
The complaint/grievance log for July 2016 contains 18 entries documented as "complaints". The documentation of the complaint "status" sections for each of the complaints contain "unknown" as an entry. The current RM did not comment on the follow-up for these entries.
8/2/16: Patient #66--no documentation of status /interventions/follow-up
8/8/16: Patient #65- - no documentation of status /interventions/follow-up
10/14/16: Patient #68 - no documentation of status /interventions/follow-up

An interview with the RM was conducted on 3/8/17 at 3:05 p.m. regarding the grievance findings. The interview included a review of the grievance logs and the facility form entitled "Patient Concern/Grievance Notification". The handwritten "Patient Concern/Grievance Notification" form dated 10/14/16 contains a signature of Patient #68's name. This incident contained concerns regarding medication doses and staff conduct and communication. The disposition section was blank without entry. On the same date of 10/14/16, the same Patient# 68 completed an additional grievance regarding privacy and confidentiality concerns regarding her chart information, commenting students entered her room and she observed the students in her chart. Another "Patient Concern/Grievance Notification" was without patient identifiers or disposition and contained a hand written entry "HIPPA VIOLATION".

The review of the grievances and complaints for October, November, and December 2016 contained incomplete documentation of follow up and status. The RM explained the information was difficult to locate and this is all that was available.
The RM explained she was a new hire at the facility in October 2016 and could not speak to incident occurring before her hire date. When asked about Patient #68, the RM explained the facility was a "hot mess" when she arrived. She continued to explain the facility risk management and quality programs require evaluations and interventions.
The RM explained the facility had experienced multiple surveys. The RM explained due multiple surveys investigations or interventions regarding the risk management and quality programs including the grievance and complaints lacked follow-up. The RM commented "the processes" for indicators and interventions for trending or audits were not "in place" at the time of survey. The RM verified she completed staff education performed for immediate intervention, but the follow up to insure effectiveness of the education intervention did not take place.

An interview conducted with the corporate director of Clinical Services on 3/8/17 at 4:45 p.m. included a review of the grievance findings. The corporate director of Clinical Services explained the expectation would be the grievance information would be complete with explanation of interventions, plans for resolutions, including correspondence and final status.
The corporate director of Clinical Services explained the facility was without a risk manager and quality manager for a few months. She explained the facility assigned the infection control nurse the additional responsibilities of risk management and quality.
The corporate director of Clinical Services explained the company did not intervene with assistance with the risk, quality, or infection control programs during the time the facility had not filled the position for risk and quality manager.
The corporate director of Clinical services did comment she was aware the company had sent assistance to other facilities during periods of employee searches to insure program success, but this did not occur with this facility.

Based on interview and review of quality assurance minutes, the hospital failed to ensure the identifications of opportunities for improvement included changes as needed, and included tracking of measures to ensure the improvement was sustained.

The findings included:

1. A review of the quality improvement meetings conducted with the new risk/quality assurance manager revealed the first meeting was on 10/26/16. The next was 11/22/16. No meeting was held in January.
The most recent meeting was held in February. This review revealed an issue was identified with falls. On 3/8/17 at 10:31 a.m., the risk/quality manager said they did training. She said they have not done any evaluation to ensure the training was effective, and was having a positive effect on falls. She said in January there was an incident report related to a medication error. It was identified as an error in transcription. Inservices were held with all nursing staff. She does not know if there was any improvement in the medication errors related to the inservices.

2. A meeting was held to address a patient focus review done by the risk/quality assurance manager. She said others attended the meeting but there was no documentation of who attended or the date of the meeting. They identified no issues with the hospital as the incident occurred after discharge. The patient died the day after discharge. The meeting identified several areas of improvement for the hospital which included patients are not to be discharged on Fridays and to encourage the use of the outpatient program for patients. On 3/10/17 at 1:30 p.m., the risk/quality assurance manager said nothing has been done to follow through with these areas for improvement.

3. A review of the incident report logs for October, November and December of 2016 revealed trending in the areas of falls, medication errors, contraband, and a very high level of patients transferred to higher levels of care. The review revealed the medication areas involved included administration, transcription, 24 hour audits, pharmacy fill errors, and omitted medications. These involve the entire medication administration practices of the facility. On 3/8/17 at 4:49 p.m. the CNO (chief nursing officer) and the risk/quality manager indicated they had identified there were issues with medications. They admitted they had not assessed the medication system as a whole to determined the effectiveness of the system.

4. On 3/8/17 at 4:49 p.m. the risk/quality manager said she had just started in October of 2016. There had not been anyone in the position for many months. She said the Joint Commission for Accreditation of Hospitals, had just come in. She had been working on completing the plan of correction for them and having them come back to resurvey. They had just finished their survey. She has another plan of correction to write for the Joint Commission to be completed by the end of March. She also said the Federal Validation and the Federal Psychiatric surveys had made her unable to do all of her other work.

Based on a review of incident reports, quality assurance meetings, and governing body meeting minutes, and interview with the risk/quality assurance manager, the hospital failed to ensure the incident reporting system was utilized to analyze the causes of complaints, and implement preventative actions.


The findings included:

1. A review of the quality improvement meetings conducted with the new risk/quality assurance manager revealed the first meeting was done on 10/26/16. The next meeting was 11/22/16. No meeting was held in January. The most recent meeting was held in February. A review revealed an issue was identified with falls. On 3/8/17 at 10:31 a.m., the risk/quality manager said they did training. She agreed they have not done any evaluation to ensure the training was effective and it had a positive effect on falls. She said in January there was an incident report related to a medication error. It was identified as an error in transcription and inservices were held with all nursing staff. She does not know if there was any improvement in the medication errors related to this inservice.

2. A patient focus review was done by the risk/quality assurance manager who said others attended the meeting but there was no documentation of who attended or the date of the meeting. They identified no issues with the hospital as the incident occurred after discharge. The patient died the day after discharge. The meeting identified several areas of improvement for the hospital which included patients not to be discharged on Fridays and to encourage the use of the outpatient program for patients. On 3/10/17 at 1:30 p.m., the risk/quality assurance manager said nothing has been done to follow through with these areas for improvement.

3. A review of the incident report logs for October, November and December of 2016 revealed trending in the areas of falls, medication errors, contraband, and a very high level of patients transferred to higher levels of care. The review revealed the medications areas involved included, administration, transcription, 24 hour audits, pharmacy fill errors, and omitted medications, which involve the entire medication administration practices of the facility. On 3/8/17 at 4:49 p.m. the CNO (chief nursing officer) and the risk/quality manager indicated they had identified there were issues with medications. They said they had not assessed the medication system as a whole to determined the effectiveness of the system.

4. On 3/8/17 at 4:49 p.m., the risk/quality manager said she was hired in October of 2016. There had not been anyone in the position for many months. She said the Joint Commission for Accreditation of Hospitals had just come in. She had been working on completing the plan of correction for them, and having them come back to resurvey. They had just finished their survey. She has another plan of correction to write for the Joint Commission to be completed by the end of March. She also said the Federal Validation and the Federal Psychiatric surveys had made her unable to do all of her other work.

Based on a review of quality assurance minutes, and interview with the risk/quality assurance manager the hospital failed to ensure there were improvement projects identified and in progress.

The findings included:

1. Review of the quality assurance minutes on 3/8/17 showed meetings on 10/26/16, November 22, 2016, a meeting in December, none in January and one in February. There was no mention in the minutes of any quality assurance projects being undertaken by the hospital. On 3/8/17 at 10:31 p.m. the risk/quality assurance manager said they had not started any projects identified by the hospital for improvement.

Based on a review of quality assurance minutes, interview with both administrative and clinical staff, the hospital administration failed to ensure there was an effective, active, ongoing quality assurance program in place, involving all departments and did not ensure there was any distinct quality assurance improvement projects conducted annually for the hospital.

The findings included:

1. A review of the quality improvement meetings conducted with the new risk/quality assurance manager revealed the first meeting was done on 10/26/16. The next meeting was 11/22/16. No meeting was held in January. The most recent meeting was held in February. The February meeting revealed an issue was identified with falls. On 3/8/17 at 10:31 a.m., the risk/quality manager said they did training. She agreed they have not done any evaluation to ensure the training was effective and was having a positive effect on falls. She said in January there was an incident report related to a medication error. It was identified as an error in transcription and an inservices was held with all nursing staff. She does not know if there was any improvement in the medication errors related to this issue.

2. A patient focus review meeting held to review work done by the risk/quality assurance manager who said others attended the meeting, but there was no documentation of who attended or the date of the meeting. They did not identify any issues with the hospital, as the incident occurred after discharge. The patient died the day after discharge. In the meeting, several areas of improvement were identified for the hospital which included patients to not be discharged on Fridays and to encourage the use of the outpatient program for patients. On 3/10/17 at 1:30 p.m., the risk/quality manager indicated nothing has been done to follow through with these area for improvement.

3. A review of the incident report logs for October, November and December of 2016 revealed trending in the areas of falls, medication errors, contraband, and a very high level of patients transferred to higher levels of care. Further reviewed revealed the medications areas involved included, administration, transcription, 24 hour audits, pharmacy fill errors, and omitted medications, which involve the entire medication administration practices of the facility. On 3/8/17 at 4:49 p.m. the CNO (chief nursing officer) and the risk/quality manager indicated they had identified there were issues with medications. They said they had not assessed the medication system as a whole to determined the effectiveness of the system.

4. On 3/8/17 at 4:49 p.m. the risk/quality manager indicated she had just started in October of 2016. There had not been anyone in the position for many months. She said the Joint Commission for Accreditation of Hospitals had just come. She had been working on completing the plan of correction for them, and preparing for resurvey. She has another plan of correction to write for the Joint Commission to be completed by the end of March. She also said the Federal Validation and the Federal psychiatric surveys had made her unable to do all of her other work.

5. Review of the quality assurance minutes on 3/8/17 showed meetings on 10/26/16, 11/22/16, a meeting in December, none in January and one in February. There was no mention in the minutes of any quality assurance projects being undertaken by the hospital. On 3/8/17 at 10:31 p.m. the risk/quality assurance manager said they had not started any projects identified by the hospital for improvement. Further review revealed there was no documentation which showed all hospital departments were involved in quality assurance.

Based on observation, interview with managerial staff, and review of quality assurance minutes, the hospital failed to provide sufficient resources to ensure quality assurance was an active and ongoing program to measure, assess, improve and sustain the hospitals performance and reducing risk for all patients.

The findings included:

1. On 3/8/17 at 10:31 a.m. the risk/quality manager admitted she had walked into a "hot mess". There had been no one in the position for several months, and she indicated the former person had walked out leaving any information locked and inaccessible. She said since she started she had a survey with the Joint Commission for Hospitals. She had to create a plan of correction for them. They have returned to the hospital and cleared some issues, but they have more issues and she has to write a plan of correction by the end of March for them. Additionally she has had the Federal and State Validations surveys, and a Federal psychiatric survey and will have to write reports for these also. She has been responsible for the entire risk management activities and any quality assurance activities for the hospital has by herself since she started.

2. The quality program had not been using incident reports to assist in identification of issues. There was no analysis of the systems involved, no interventions with the programs, and no assessments of effectiveness of interventions. There was no quality assurance program in place. On 3/8/17 at 4:49 p.m., the Chief Nursing Officer admitted the rest of the hospital departments were not doing any quality assurance programs within their departments.




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3. An interview with the Corporate Director of Clinical Services conducted on 3/8/17 at 4:45 p.m. verified the facility lacked a Risk Manger and a Quality Manager. The Corporate Director explained the facility assigned the infection control nurse the additional responsibilities of risk management and quality management. The corporate director of Clinical Services explained the facility was without a risk manager and quality manager for a few months.

The corporate director of Clinical Services explained the company did not intervene with assistance with the risk or quality during the time the facility had not filled the position for risk and quality manager. The corporate director commented she was aware the company had sent assistance to other facilities during periods of employee searches to insure program success, but this did not occur with this facility.

A review of the grievance findings conducted with the Corporate Director. The corporate director explained the expectation would be the grievance information would be complete with explanation of interventions, plans for resolutions, including correspondence and final status.

Based on observation, staff and patient interviews, and record and policy reviews, the facility failed to provide nursing services to meet the needs of the patients for oversight of staff with 15-minute patient checks, medication education, and patient care with medication education and administering medication.

The findings included:

1. On 3/6/17 a review of Patients #20, #21, #43, #57, #59 and #60 fifteen-minute check sheets revealed Mental Health Technician (MHT) Staff AAA, and MHT Staff D were behind in documenting their observations. A review of Patients # 43, #61 and #62 revealed Social Worker Staff BBB and CCC had documented their observations before the time of the observations. An observation of Patient #63 and review of 15 minute check sheets revealed Staff PP documented an observation of the patient on the 15-minute check sheet when Patient #63 was not visible. Staff PP confirmed he could not see patient.

On 3/8/17, RN Supervisor Staff WW,Social Worker Staff BBB, and MHT Staff DDD observed Patient #46 walking around the unit with a long blue scarf wrapped around his waist. Patient #46's said his wife gave him the scarf on 3/7/17. The staff failed to check in the scarf and record on his belongings sheet, as per policy.

2. On 3/8/17 and 3/9/17 a review of Patients #30, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, and
#56 medical charts revealed they had not received medication education. LPN Staff TT said she uses the 2015 Nursing Drug handbook to educate patients.

On 3/8/17, Patient #46 said she started on new medications and did not receive medication education.

3. On 3/8/17, a review of Patients # 30, #42, #47, #50 and #53 Medication Administration Record revealed Licensed Practical Nurse (LPN) Staff SS administered their medications after 1 hour of their scheduled time. Staff RN Supervisor Staff WW confirmed LPN Staff SS did not follow the policy for medication administration.

4. On 3/8/17, a review of Patient #44's Medication Administration Record (MAR) and Insulin Record revealed Patient #44 had insulin ordered as a scheduled medication. LPN Staff SS reviewed the MAR and acknowledged unknown nurses gave Patient #44 Humalog insulin according to a sliding scale. Patient #44 does not have an order for Humalog insulin.

5. On 3/9/17 a review of Patient #35's MAR revealed LPN Staff TT had documented Patient #35 was given 9:00 a.m., dose of Haldol and Cogentin intramuscularly (IM) prior to administering the medication and without documenting Patient #35 had refused oral medication. Staff TT was observed after 9:00 a.m., with Patient #35 telling her if she refused her medications by mouth, the medications would have to be given IM. Patient #35 said she wanted the medication orally.

6. On 3/8/17 Patient #41 had an Emergency Treatment Order (ETO) and received 2 ETOs. On 3/10/17, RN Supervisor Staff UU confirmed on 3/8/17, he had administered the ETO for Patient #35. A review of the MAR for Patient #41 revealed Staff UU failed to document the ETO medication and as having administered.

Based on observation and staff interviews, the facility failed to provide adequate staff to deliver nursing care to all patients as needed. The facility nurse failed to provide oversight for 9 (Patients #20, #21, #43, #46, #57, #59, #60, #61, #62, and #63) out of 64 sampled patients.

The findings included:

1. A review of the 15 minute checks sheets on 3/6/17 and 3/7/17 revealed the following:

On 3/6/17 at 11:32 a.m., observed MHT (mental health technician) Staff AAA, sitting in Patient #43's room. Staff AAA stated "[patients name]who is Patient #43, is on 1:1 and is checked every 15 minutes. I have to stay with him. Review of the 15-minute check sheet revealed 10:45 a.m., was the last 15 minute check documented. Staff AAA said he was just going to update the documentation.

On 3/6/17 at 3:35 p.m., a review of Patient #43's 15 minute check sheet revealed MHT Staff C had already initialed and documented the behavior for Patient #43's activity at 3:45 p.m. Staff C said he documented it for 3:45 p.m., "because I knew I was gonna be here."

2. On 3/6/17 at 12:03 p.m., observed MHT Staff D assisting patients in dining room. MHT Staff E said Staff D had given her the 15-minute check sheets for #20, #21, #57, #59, and #60. Review of the 15-minute check sheets for #20, #21, #57, #59, and #60 revealed the last 15 minute check was documented at 11:10 a.m.

3. On 3/6/17 at 11:55 a.m., Patient #63 was observed talking on the telephone. At 12:15 p.m., a review of the 15-minute check sheet revealed MHT Staff PP had initialed it and documented her behavior and activity for 12:00 p.m. He said Patient #63 already ate lunch in the dining room, and went back to the unit. At 12:16 p.m., he acknowledged Patient #63 had not been in the dining room, she was on the unit. He confirmed he was not able to see her from the dining room. On the unit, RN Staff EEE said the patient went into the common area and would be eating lunch on the unit. She said she is watching her for the 15-minute checks but she did not have her 15-minute check sheet .

4. On 3/6/17 at 12:10 p.m., review of the 15-minute check sheets for Patients # 61 and #62 revealed MHT Staff CCC documented their behavior and activity before the time of the check.

5. On 3/8/17 at 9:45 a.m., observed Patient # 46 on the unit walking around in a mid-calf blue hospital gown with a piece of blue cloth wrapped around his waist hanging to mid-calf. At 10:30 a.m., observed Patient #46 dressed the same, during a group session held by social worker Staff BBB. At 11:35 a.m., observed RN Supervisor Staff WW ask Patient #46 for the blue cloth wrapped around his waist. The patient unwrapped the long blue cloth and gave it to her. At 11:37 a.m., MHT Staff DDD stated "Patient #46 had this scarf wrapped him and Staff WW took it from him because he can't have it." She said Staff WW told her his wife gave it to him at visitation last night. Staff DDD explained she would need to log Patient #46's scarf into his belongings list. She said, he would not get something like this back. The patient was told the hospital would hold it for him because it could be dangerous.

6. On 3/9/17 at 1:00 p.m., RN supervisor Staff WW said there is not enough staff so she can spend time with the patients. She said she really has not had the time to see them today. She said she really needs another nurse. She said today she has had four patient discharges. She said yesterday, a physician ordered a blood draw, and it was not drawn. Today she had to stop what she was doing, and had to draw the blood today as a stat (urgent) blood draw. She said she had to complete the incident report and call the Chief Nursing Officer to tell her. She said while doing all of this, she is taking off MD orders and is supposed to help the medication nurse. She said she is overwhelmed at times. She said she has spoken up to administration to let them know she really needs more help.

Review of the facility policy for Patient Observation dated 5/20/15, documents the "documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and/or to back fill timeframes that were not completed in a timely manner." "During rounds staff are to make direct visual contact."

Review of the facility's policy for Visitation and Telephone use dated 2/19/13 documents visitors must go to the nurses' station prior to seeing patients on the unit, present identification and sign in. Items brought for the patient will be checked by staff, and the policy for contraband will be strictly followed."

Based on observation, staff and patient interviews ,and review of facility policy, the facility failed to provide medication education for 13 ( Patient #30, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, and #56) of 13 patients sampled for medication education out of 64 sampled patients and failed to ensure care was provided as ordered 2 patients #69 and #36.

The findings included:

Review of the facility policy for Informed Consent, Medications documented the procedure as "the nurse on the unit will discuss prescribed medications with the patient at the time of admission or at the time the new psychotropic medication is ordered. The discussion will be based on written medication information sheets generated and approved by US Pharmacopeias Drug Information approved sources. Written medication sheets will be given to the patients. the nurse, physician or pharmacist will follow the process when medications are changed or added ..."

On 3/8/17 at 10:00 a.m., Licensed Practical Nurse Staff SS, said medication administration starts between 8:00- 8:30 a.m. and it takes about 1- 1 ½ hours to complete it. She said if the patient has started on a new medication, she gives the patients a medication education sheet for the medications. She said she offers the medication education sheet to them, sometimes they take it while other times they read it and hand it back to her. She said she does not give the patients a medication education sheet that have been on the medications a long time or if they were taking it before their admission, because "they already know the side effects for them."

3/8/17 at 11:02 a.m., Patient #46 said she had started four new medications she had never taken before. She said last night she asked the night nurse for the education sheets and he gave her two medication sheets out of the four medications she takes. She said the night nurse handed her the medication education sheets but no one spoke to her about them.

On 3/8/17, a review of Patient's #30, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, and #56 failed to reveal documentation of medication education.

On 3/8/17 observation during morning medication administration with Staff SS, she failed to educate the patients for possible side effects.

On 3/9/17 at 10:03 a.m., LPN Staff TT said if a patient asks her about their medication and she does not know the side effects of it or what it is for, she will look it up in the Nursing Drug Handbook. A Nursing Drug Handbook dated 2015 was observed on a shelf above the counter in medication room. She said it is not something she offers to the patient, but will do it if they ask about their medication.

On 3/9/17 at 10:58 a.m., RN supervisor Staff WW said, the medication nurse does the medication education. She said she does not do it. She confirmed there is no documentation in the patients medical chart for medication education stating "we don't put anything in there for that."


09353


Patient #36 had physician's orders dated 12/26/16 for a dentist and a podiatrist. A review of the record revealed the order was signed by the physician at 6:40 p.m. It was signed off by the nurse on 12/26/16 at an unknown time. There was also a note indicating there was a copy sent to the social worker. There was no evidence in the record about either referral being made to the appropriate provider, nor was there evidence either referral was ever implemented. On 3/10/17 at 1:30 p.m., the Director of Clinical Services Staff K agreed there was no documentation on the record about these orders and the reason they were not implemented.


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A review of the clinical record for Patient #69 was conducted on 3/8/17. The record included a facility Treatment Orders sheet. An order was dated 3/7/17 at 2:15 p.m. The handwritten order included "AM labs: Vit D (Vitamin D), depakote level".

A review of the treatment orders dated 3/9/17 include "depakote level STAT (immediately)" and "hold depakote".

The Chief Nursing Officer verified the Depakote level ordered for 3/8/17 was omitted / not drawn by the facility clinical/nursing staff.

Based on observation and staff interview, the facility failed to supervise a contract staff so they followed the hospital's policy for medication administration for 1 (Patient #64) out 1 sampled patient during medication administration.

The findings included:

On 3/10/17 at 11:20 a.m., review of Patient #64's Medication Administration Record (MAR) revealed Contract LPN (agency) Staff VV initialed as administering Patient #64's 11:00 a.m. dose of Pom-Creon. He said when he sets up the medication in the medication cup; he will put a dot next to the medication. Staff VV said he initials it when Patient #64 takes it. He said he has not given Patient #64 the 11:00 a.m. medication yet, she should be up here in a few minutes. He acknowledged his initials are on the MAR for Patient #64 for the 11:00 a.m. medication, and there is no dot next to it.

A review of the policy for Medication Administration dated 8/28/15 documented, "Administration: Medications must be administered within 1 hour of the designated scheduled time. Report drug administration errors and adverse or untoward drug reactions immediately to the attending physician, pharmacist, and patient and/or family. Prepare and submit reports as required by the facility. Check patient's MAR to ensure that the order is accurate: verify patient, medication, dosage, route, frequency, stop date. Read the drug label. Document on the MAR the following information in the appropriate column: dose, time, route (if not by mouth) site and initials. Sign the bottom of the MAR where indicated."

Based on observation, staff interviews and policy review, the facility failed to administer medications within the timeframe for 6 (Patients #30, #32, #35, #42, #47, #50, and #53) out of 13 patients sampled for medication administration. The facility nurse failed to administer insulin medication as ordered for 1(Patient # 44) out of 2 sampled patients for insulin. The facility failed to appropriately document for 1 (Patient #41) out 1 patient sampled for Emergency Treatment Orders.

The findings included:

1. On 3/8/17 from 9:45 a.m. to 11:05 a.m., observation during medication administration revealed Licensed Practical Nurse (LPN) Staff SS administered Patient's #30, #42, #47, #50, and #53. The scheduled medication for 9:00 a.m., was administered after 10:00 a.m.

On 3/8/17 at 10:50 a.m., RN Supervisor Staff WW acknowledged there are four Styrofoam cups with medications in them. They were Patients #38, #41, #42 and #46 medication scheduled for for 9:00 a.m. LPN Staff SS stated, "I don't know what I am going to do with them, I am working on it."

On 3/9/17 at 10:58 a.m., Staff WW said the timeframe for medication administration is 1 hour before to 1 hour after the time on the MAR. She stated, "It can be 11:00 a.m. before they get it." She confirmed if the patient has not taken their medication by 10:00 a.m., the medication nurse should notify the physician and get an order to give it.

2. On 3/8/17 at 11:00 a.m., Patient #44 approached the medication room door and said she was there for her accucheck. LPN Staff SS informed her the next accucheck is at 4:00 p.m. RN Supervisor Staff WW reviewed the insulin form for Patient # 44 and said the nurses have documented for a sliding scale with Novolog insulin given on 3/7/17 and 3/8/17. She acknowledged on 3/7/17 at 4:00 p.m., an unknown nurse performed an accucheck on Patient # 44. The nurse administered four units of Novolog insulin.

On 3/8/17 at 6:00 a.m., an unknown nurse performed an accucheck on Patient # 44. The nurse administered four units of Novolog insulin, with a second nurse initialing the Medication Administration Record (MAR) as confirming the insulin. LPN Staff SS is unable to determine who the nurses are by their initials. Patient #44 does not have a physician order for Novolog insulin or a sliding scale. Staff SS stated, "They keep doing this, putting it on the wrong form. She does not get sliding scale, her insulin is scheduled and she gets an accucheck done twice a day. It belongs on this other form." Staff SS acknowledged the sliding scale form indicates Patient # 44 received Novolog insulin based on sliding scale. On 3/7/17 only one nurse initialed, (there should to be two nurses' initials). She confirmed there was no documentation on the patient's MAR for Novolog insulin to account for the four units of insulin given on two occasions.

A review of physician orders revealed an order dated 3/6/17 which documented Patient #44 is prescribed Lantus 25 units every evening and Humalog 5 units before meals. There is a physician order for accuchecks twice a day.

On 3/9/17 at 10:15 a.m., RN Supervisior Staff WW said she is unable to locate the sliding scale order for Patient #44. She said according to the physician order dated 3/6/17, she is not on sliding scale. She is to have accuchecks twice a day, and 25 Units insulin at night and 5 units before each meal. She acknowledged the form in her chart for sliding scale coverage and stated, "This is the nurse who is a Nurse Practitioner that is doing this; many medication errors happen. She said staff SS did not tell her about this yesterday. She said a incident report needs to be completed when there is a medication error. She acknowledged LPN Staff SS did not follow the medication administration and reporting medication errors policy.

3. On 3/9/17 at 10:00 a.m., observed LPN Staff TT exiting Patient #35's room. She said she was her last patient for medication. She said Patient # 35 had been refusing her medication this morning. Staff TT stated, "I told her if she did not take it by mouth, I would have to give by IM, but now she said she would take it." Review of Patient #35's MAR revealed an order for Haldol by mouth, if refuses give IM and Cogentin by mouth, if refuses give IM. The 9:00 a.m. doses for the Haldol and Cogentin are circled, and IM, with staff initials is written under it. Staff TT said when you circle a time it means they refused it. Staff TT stated, "It's like that because she thought she would have to give it to her IM."

4. On 3/9/17 at 12:45 p.m., Patient # 41 said two nights ago she the nurse got an Emergency Treatment Order (ETO) and gave her two shots. One shot was for Haldol and the other for Ativan. A review of Patients #41 MAR did not reveal she received the ETO.

On 3/10/17 at 9:00 a.m., RN Staff RR and RN Supervisor Staff UU confirmed Patient #41 received an ETO of Haldol and Ativan on 3/8/17. Staff UU said he was the nurse that gave it.

A review of the policy for Medication Administration dated 8/28/15 documented "Orders: Only Practitioner who are lawfully authorized to prescribe and credentialed by the hospital may write orders for medication." Administration: "two nurses must check the dosage and prepare amount for insulin. Medications must be administered within 1 hour of the designated scheduled time. Report drug administration errors and adverse or untoward drug reactions immediately to the attending physician, pharmacist, and patient and /or family. Prepare and submit reports as required by the facility. Check patient's MAR to ensure that the order is accurate: verify patient, medication, dosage, route, frequency, stop date. Read the drug label. Document on the MAR the following information in the appropriate column: dose, time, route (if not by mouth) site and initials. Sign the bottom of the MAR where indicated."

A review of the policy for Insulin Administration dated 10/2012 "...all insulin doses must be checked by the administration nurse and a witness" "all insulin is measured in units. No matter what insulin is administered, always monitor and record on MAR the number of units administered. Record on the MAR the time of the injection, the amount of insulin, and the injection site. All insulin doses (type and amount) and syringe must be verified and documented by the administration nurse and a witness prior to patient administration. To promote consistency in sliding scale coverage and diabetic coverage, the order sheet for Insulin Dependent Diabetes Mellitus should be used."


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5. On 3/6/17, a review of the Patient #32's clinical record occurred.
The facility form entitled "Practitioner Order" (used as a physician order sheet) contained a handwritten entry on 2/24/16 at "12 AM" including an order to "d/c (discontinue) Zoloft".

A review of the Medication Administration Record (MAR) for a four day period dated 2/23/16, included 2/23/2016 to 2/26/16. The Zoloft 100 milligram (mg) 1 tablet PO (by mouth) daily dose was documented as administered on 2/23/16 and 2/24/16 at 9:00 a.m. On the 2/23/2026 MAR, a handwritten entry noted: "DC'd (discontinued) 2/24/16" with a nurse initial placed below the note.

A review of the Medication Administration Record (MAR) for a three day period dated Saturday February 27, 2016 included the dates 2/27/16 to 2/29/16.
The MAR documentation of the Zoloft 100 mg 1 tablet PO (by mouth), daily dose is administered at 9:00 a.m. on 2/27/16 and 2/28/16.

An interview with the Risk Manager conducted on 3/8/17 at 3: 45 p.m. with an affirmative verification of the finding.

Based on administrative and pharmacy interviews, record reviews, and facility policy and procedure, the facility failed to ensure to have a system to notify the physicians of medications with potentially harmful interactions for 1 (patient #39) of 40 patient records reviewed.

The findings included:

1. Patient #39 was admitted to the hospital on 12/22/17 as an involuntary admission and was discharged on 12/30/16. The evaluation indicated the patient was alert and oriented at the time of admission. The physician sent her home on Celexa, Depakote, Vistaril, and Abilify. A review of the drug interactions noted in WebMD showed the Celexa and Vistaril have a serious interaction which can cause a severe cardiac rhythm issue and sudden death. This interaction was deemed serious and alternative drugs should be used. The Vistaril and the Abilify will interact together by increasing sedation, caution should be used with these 2 drugs, and the patient should be monitored.

2. A review of the policy and procedure related to "new order handling" dated 1/1/2012, indicated the pharmacist was to check for the appropriateness of the order. The computer would check for drug interactions when the medication order was entered into the computer. After the order was to be processed, the pharmacist would do a final check and then call the nurse or the physician for order clarification with the appropriate intervention. The policy had no mechanism to ensure the process was followed and interventions were made as necessary.


3. On 3/10/17 at 1:30 p.m., the Pharmacist said the computer checks for interactions and colors them purple. She said she called on what she has, but to be honest and she did not do as much documentation as she should. If she was not present the alternate pharmacist would leave a note for her to handle any issues upon her return. She said she called the doctors to communicate, but she did not document this. She agreed she had no documentation the issues with Patient #39's medications were evaluated for interactions, or the physician notified of the serious potential for interactions between medications.

Based on patient diets reviewed, facility staff interview, facility menu review and observations, the facility failed to provide the prescribed diets at the lunch meal for 2 (Patients #20 and #21) of 3 patients sampled.

The findings included:

A review of Patients #20 and #21's diet orders showed Patient #20 was on a 2 gram sodium diet dated 2/24/17 and Patient #21's was on a consistent carbohydrate diet dated 3/1/17.

A review of the facility lunch menu for 3/7/17 showed the 2 gram sodium diet received buttered pasta and cole slaw and patients on the consistent carbohydrate diet received 1/2 bun for their sloppy Joe sandwich.

Observation on 3/7/17 at 11:45 a.m. showed Patient #20 did not receive butter pasta and cole slaw with her lunch, and Patient #21 received a whole bun with her sloppy Joe sandwich.

On 3/7/17 at 1:45 p.m., the facility's Director of Food Service said he was not aware these two patients did not get their prescribed diet.

Based on staff interviews on 3/6/17 at 2:00 p.m. the facility had not developed their Utilization Review Committee and had no policy and procedures to meet the UR plan (refer to A 653 and A654): No Utilization Review Committee (URC) had developed a plan to provide review for Medicare and Medicaid patients (refer to A655); the URC did not determine the if the admission or continued stay at the facility is medically necessary (refer to A656); since the hospital is not paid under the prospective payment system, the facility did not review patients with extended stays (refer to A657); and the facility did not review the professional services provided to ensure the patients are receiving the most effective use of services and health care facilities (refer to A658).

Based on facility staff interview, the facility had not developed a Utilization Committee and had no policies and procedures.

The findings included:

On 3/6/17 at 2:00 p.m., the Director of Utilization Review (DUR) and the Chief Financial Officer (CFO) said at this time, the hospital did not have a Utilization Review Committee (URC). The DUR was in the process of developing this committee. The URC had not assumed binding review for the hospital and there were no UR procedures written specifically for this hospital.

Based on facility staff interview, the facility has not developed a Utilization Review Committee (URC) and assign staff to this committee.

The findings included:

An interview was conducted with the Director of Utilization Review and the Chief Financial Officer (CFO) on 3/6/17 at 2:00 p.m. They stated their plan is to have two physicians, the Director of Social Services, 1 nurse from a unit and another nurse from intake, CFO and anyone else that is appropriate. At this time they have not had any meetings.

Based on facility staff interview, and facility record review, the facility had not developed a Utilization Review Committee and had no Utilization Review Plan developed to review patients with Medicare and Medicaid to ensure medical necessity of services.

The findings included:

On 3/6/17 at 2:00 p.m., the Director of Utilization Review (DUR) said she did not have this committee organized as of yet. However, she had a form monitoring patients' admission to ensure it is necessary. She said she had not used this form for any patients at this time.

A review of "Traditional Medicare UR (utilization Review) Inpatient Admission Oversight" form showed the form was for the review of patients with Medicare coverage. The DUR said they did not review patients with Medicaid only. They will admit patients with Medicaid under Baker Act. Then the business office staff will meet with the patient and qualify them as charity.

Based on facility staff interview, and record review, the facility did not have a Utilization Review Committee to determine if patients that are admitted or had a continued stay were not medically necessary.

The findings included:

On 3/6/17 at 2:00 p.m., the Director of Utilization Review (DUR) said she did not have this committee organized as of yet. However, she had a form monitoring patients' admission to ensure it is necessary. She said she had not used this form for any patients at this time.

A review of "Traditional Medicare UR (Utilization Review) Inpatient Admission Oversight" form showed a review for admission medical necessity.

Based on facility staff interview, the facility had not developed a Utilization Review Committee or Utilization Review plan to review each inpatients extended stay.

The findings included:

On 3/6/17 at 2:00 p.m., the Director of Utilization Review (DUR) said the facility had not developed a Utilization Review Committee or Utilization Review plan. They had not reviewed any patients extended stays.

Based on facility staff interview, the facility had not developed a Utilization Review Committee to review professional services and other health facilities to best suit their patients.

The findings included:

On 3/6/17 at 2:00 p.m., the Director of Utilization Review (DUR) said the facility had not developed a Utilization Review Committee. They had not begun the review of professional services to determine the most efficient use of the health facilities and services that are available for each of their patients.

Based on observation and staff interviews, the facility failed to post signage informing and indicating the hospital was a psychiatric hospital.

The findings included:

On 3/7/17 at 11:35 a.m., the Chief Nursing Officer said the sign outdoors said psychiatric urgent care. She said there was nothing posted for signage inside. People would just know when they came through the door. She said they had dealt with that many times. If someone came in, the staff clarify the patient needs. If there was an emergency, they call a code. She said there was nursing services available and the nurse would stabilize the patient and transfer them to a hospital to meet their medical needs. She said the receptionist would tell people walking in, this is a psychiatric hospital and not a medical hospital.

On 3/7/17 at 12:15 p.m., the Director of Outpatient Services acknowledged during the tour of the receiving area for Baker Acts, there was no signage indicting what type of hospital this is. She acknowledged the front of the hospital, and the waiting area inside the entrance to the hospital there was no signage to indicate this was a psychiatric only treating facility. The Director of Outpatient Services confirmed the only signage was in the case next to the receptionist desk. She acknowledged you are unable to see the signage when entering the hospital.

On 3/7/17 at 12:33 p.m., the Receptionist, Staff KK said if a person came here with a medical emergency by accident thinking this was a medical hospital, she would "assess them for the medical problem." If they were bleeding, she "would assess the issue to see if they were bleeding profusely." She said she would contact the Infection Control Nurse or the intake nurse. She said they are not a medical facility and stated, "We don't do medical treatment here." (The receptionist, Staff KK had no Medical or Mental Health background).

On 3/8/17 at 5:15 p.m., the Director of Corporate Services said there is a sign outside that says psychiatric hospital. The receptionist should never assess, just call intake nurse or DON.

** photo evidence on file **