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Based on medical record review, review of hospital policy and interview, the hospital grievance policy lacked direction for grievance response after the patient was discharged. The findings include:

Patient #7 was admitted to the psychiatric hospital with a diagnosis of dementia with behavioral disturbances. Hospital documentation from Person #1 was reviewed with the Nursing Director of Psychiatric Services on 12/21/09 at 11:45 AM. The documentation from Person #1 included multiple care concerns regarding Patient #7's hospitalization from 1/3/09 to 1/14/09. Interview with Nursing Director of Psychiatric Services on 12/21/09 at 11:45 AM indicated that the concerns mentioned in Person #1's letter were different from the concerns expressed at the time that the patient was hospitalized. The Nursing Director of Psychiatric Services noted that he/she called Person #1 on 2/19/09, the day after the letter was received, spoke with Person #1 and Staff, and a written response to Person #1's concerns was not sent to Person #1. Review of the facility Grievance Policy was conducted on 12/21/09. Although the policy directed staff response to grievances during the patient's hospitalization, the policy did not direct staff response to grievances after the patient was discharged to include a written response and/or timeframes for the response.

Based on medical record review, review of hospital policies and interviews the hospital failed to provide written response to a grievance. The findings include:

Patient #7 was admitted to the psychiatric hospital with a diagnosis of dementia with behavioral disturbances. Hospital documentation from Person #1 was reviewed with the Nursing Director of Psychiatric Services on 12/21/09 at 11:45 AM. The documentation from Person #1 included multiple care concerns regarding Patient #7's hospitalization from 1/3/09 to 1/14/09. Interview with Nursing Director of Psychiatric Services on 12/21/09 at 11:45 AM indicated that the concerns mentioned in Person #1's letter were different from the concerns expressed at the time that the patient was hospitalized. The Nursing Director of Psychiatric Services noted that he/she called Person #1on 2/19/09, the day after the letter was received, spoke with Person #1 and Staff, and a written response to Person #1's concerns was not sent to Person #1. The hospitals grievance policy identified that a grievance was an actual or supposed wrong expressed by a patient and/or family member whereby the facility did not meet the reasonable expectations of the individual and/or family. Although the policy indicated that the primary therapist would investigate the grievance or concern and attempt to resolve it, the procedure did not direct staff for written follow up to a grievance.

Based on medical record review, review of hospital policies and interviews for one of thirteen patients who required staff assistance for bathing (Patient #7), the hospital failed to provide the patient with a shower per family request. The findings include:

Patient #7 was admitted to the psychiatric hospital via a physician's emergency certificate with a diagnosis of dementia with behavioral disturbances. Person #1 was the responsible party for Patient #7. The physician's admission evaluation dated 1/3/09 identified that the patient's dementia was severe and the patient was essentially non communicative. The assessment dated 1/3/09 identified that the patient was lethargic. The care plan dated 1/5/09 directed the assistance of staff for activities of daily living. Nursing narratives dated 1/9/09 at 6:33 AM indicated that Person #1 requested that Patient #7 receive a shower and shave. The narrative also identified that Person #1 was informed that Patient #7's shower day was due every Saturday on the evening shift and that Person #1 continued with the request. Nursing narratives and/or nurse aide flow records lacked documentation that Patient #7 received a shower or shave from 1/9/09 to 1/13/09 to include the scheduled shower day of Saturday, 1/10/09. Interview with the Nursing Director of Psychiatric Services on 12/29/09 at 11:20 AM noted that although a shower schedule was in place, a patient would receive a shower when soiled or per request. The hospital patient care policy directed that bed baths would be done by nursing when needed in between showers or tub baths and lacked documentation for the routine frequency of showering/tub baths. Hospital Policies for the Patients' Bill of Rights identified that the patient had the right to be involved in decisions affecting treatment and that the patient's guardian/next of kin would become the patient's designated advocate for patient rights if the patient was found medically incapable.

Based on clinical record review, review of hospital policies, and interviews with staff for four patients (Patients #10, and #11 and #3 and #7), who were admitted for psychiatric treatment, the hospital failed to ensure that nursing assessments were conducted and/or documented prior to the application of restraints and/or that a physician's order for the restraint was obtained. The findings include:

a. Patient #10 was admitted on 12/14/09 with a diagnosis of dementia. Review of the patient's care plan identified a problem of risk of injury related to mental status changes with an intervention to use a less restrictive device before using a protective restraint, as needed. Observation of the patient and review of the clinical record with the Director of Nursing on 12/30/09 at 9:45 AM identified that Patient #10 was seated in a chair with a belt around the patient's waist. Staff identified that the belt was not a restraint as it was self-releasing. However, when Patient #10 was asked to release the belt, the patient was unable to do so. The clinical record lacked a current assessment of the patient's need for the use of a waist belt, and failed to identify if the waist belt was needed for behavioral purposes. The hospital policy for restraints identified that a restraint is a device that restricts a patient's movement and that the patient cannot easily remove. The decision to restrain a patient is driven by a comprehensive assessment.
b. Patient #11 was admitted on 12/23/09 with diagnoses that included Parkinson's disease and experienced delusions and paranoia. Review of the patient's care plan identified a problem of risk of injury related to mental status changes with an intervention to use a less restrictive device before using a protective restraint, as needed. Observation of the patient and review of the clinical record with the Director of Nursing on 12/30/09 at 9:45 AM identified that Patient #11 was seated in a chair with a belt around the patient's waist. Staff identified that the belt was not a restraint as it was self-releasing. However, when Patient #11 was asked to release the belt, the patient was unable to do so. The clinical record lacked a current assessment of the patient's need for the use of a waist belt, and failed to identify if the waist belt was needed for behavioral purposes.


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c. Patient #3 was admitted to the hospital on 12/24/09 with diagnoses of schizophrenia and vascular dementia. Physician orders dated 12/24/09 directed out of bed with assistance. The plan of care dated 12/24/09 identified that the patient was at risk for injury and approaches included to utilize the least restrictive devices, utilize a lap positioner, and restraint tool. Nursing narratives dated 12/25/09 indicated that the patient was in the wheelchair (w/c) with a self-release belt and was restless and agitated after breakfast. Nursing narratives dated 12/29/09 identified that the patient was in the w/c with the self release- belt for safety. Observation of the patient on 12/29/09 noted the patient in the wheelchair with the waist belt on. Although interview with NA #2 on 12/29/09 indicated that the patient could remove the lap belt, the record did not reflect this and the patient was unwilling to cooperate with removing the belt on 12/29/09 and 12/30/09. The patient's record was reviewed with the Nurse Education Specialist on 12/30/09 and the record lacked assessments and physician ' s orders for the use of the belt on 12/24/09 and 12/29/09. Interview with the VP of Nursing on 1/5/10 at 2:30 PM noted that the nurse was to document an assessment for the use of the restraint within the list patient notes.

d. Patient #7 was admitted to the psychiatric unit with a diagnosis of dementia with behavioral disturbances. The initial medical assessment dated 1/3/09 identified that the patient was lethargic. The fall assessment dated 1/3/09 indicated that the patient was at risk for falls. The plan of care dated 1/3/09 noted that the patient was a risk for injury and an approach to employ least restrictive devices before use of medical/surgical restraint. Patient list notes dated 1/3/09 indicated that the patient was in a Geri chair. Patient list notes (nursing narratives) dated 1/6/09 noted that the staff nurse was advised by the NA that an airline safety belt (ASB) was required at 10 AM and the nurse notified the physician for the order. The nursing narrative lacked documentation of an assessment for the use of the ASB. The physician ' s order dated 1/6/09 at 3:46 PM directed ASB from 10 AM to 10 PM. to prevent unsupervised ambulation related to fall/fracture history. Restraint flow sheets dated 1/6/09 indicated that the patient was in the chair with the ASB from 7 AM to 7: 45 AM, 11 AM to12 PM and 3:15PM to 3:30PM.

The Geriatric Medical/Psychiatric Program (GMPP) restraint policy identified that a restraint is a device that restricts a patient's movement and that the patient cannot easily remove. The decision to restrain a patient is driven by a comprehensive assessment and a physician's order must be obtained for the use of restraints. Restraints are only used when less restrictive interventions are ineffective.

Based on clinical record review, review of hospital documentation, and interviews with staff for five patients (Patients #1, 9, 10, 11, and 13) admitted to the psychiatric unit, the hospital failed to ensure that care plans identified specific groups that the patient should attend based on their diagnoses and needs; failed to address the use of restraints and oxygen requirements; and/or failed to address the patient's history of aggression towards peers. The findings include:

a. Patient #13 was admitted on 1/5/09 with a diagnosis of Alzheimer's disease with severe behavioral disturbances, and had a history of assaulting peers and staff. Between 1/5/09 and 1/15/09 the patient was identified as intrusive and assaultive to peers and staff (1/7/09 and 1/11/09). Review of Patient #13's care plan failed to identify the patient's behavioral problem of unpredictable violence and assaultive behaviors towards peers, and failed to identify safety measures to ensure the safety of peers. On 1/15/09 at 5 PM Patient #13 exhibited escalating behaviors and was identified as able to "calm down with medications." On 1/15/09 at 10:35 PM Patient #13 was found in Patient #1's room with his/her hands around Patient #1's neck. According to hospital documentation, a staff member passing by Patient #1's room witnessed Patient #13 choking Patient #1. Patient #13 was pulled away from Patient #1 and placed in seclusion.

b. In addition, Patient #13's care plan identified that the patient should attend occupational groups; however, the care plan failed to identify other therapeutic groups that the patient should attend, specific to the patient's needs. The Director of Nursing identified that patients are not assigned to a concrete group schedule, and that every patient is expected to attend every group that is offered.

c. Patient #1 was admitted on 1/6/09 with a diagnosis of schizophrenia and paranoia. Between 1/6/09 and 1/15/09 the patient was identified as verbally abusive to staff and peers and would continually scream and curse when someone passed by the patient's bedroom door. Review of Patient #1's care plan failed to identify the patient's behavioral problem of verbal abuse towards peers, and failed to identify safety measures to ensure the safety of Patient #1, and that of his/her peers. On 1/15/09 at 10:35 PM Patient #13 was found in Patient #1's room with his/her hands around Patient #1's neck. According to hospital documentation, a staff member passing by Patient #1's room witnessed Patient #13 choking Patient #1, and pulled the patient away.

d. In addition, Patient #1's care plan identified that the patient should attend occupational groups; however, the care plan failed to identify other therapeutic groups that the patient should attend, specific to the patient's needs.

e. Patient #9 was admitted on 12/28/09 with diagnoses that included schizoaffective disorder and paranoia. The patient's clinical record was reviewed with the Director of Nursing on 12/30/09. Although the care plan identified that the patient should attend occupational groups, the care plan failed to identify other therapeutic groups that the patient should attend, specific to the patient's needs. In addition, Patient #9's care plan failed to identify that the patient required oxygen and failed to identify how staff were to determine the amount of liters to administer to the patient, based on a practitioner's order to administer oxygen between 1-5 liters per minute as needed to keep the oxygen saturation rate at or above 90%.

f. In addition, Patient #9's profile (care card that staff reference to identify care the patient required) failed to identify that the patient used oxygen. The Director of Nursing identified that the patient profile should be up to date and specific to the patient's needs.

g. Patient #10 was admitted on 12/14/09 with a diagnosis of dementia. Although the care plan identified that the patient should attend occupational groups, the care plan failed to identify other therapeutic groups that the patient should attend, specific to the patient's needs.

h. In addition, Patient #10 was observed on 12/30/09 at 9:45 AM seated in a chair with a belt around the patient's waist. Staff identified that the belt was not a restraint as it was self-releasing. However, when Patient #10 was asked to release the belt, the patient was unable to do so. Subsequent to surveyor inquiry, staff identified the waist belt met the criteria for a restraint and obtained a practitioner's order for the restraint. Review of the patient's care plan failed to identify the patient's need for a waist belt.

i. In addition, Patient #10's profile (care card that staff reference to identify care the patient required) failed to identify the patient's need for a waist belt.

j. Patient #11 was admitted on 12/23/09 with diagnoses that included Parkinson's disease and experienced delusions and paranoia. Although the care plan identified that the patient should attend occupational groups, the care plan failed to identify other therapeutic groups that the patient should attend, specific to the patient's needs.

k. In addition, Patient #11 was observed on 12/30/09 at 9:45 AM seated in a chair with a belt around the patient's waist. Staff identified that the belt was not a restraint as it was self-releasing. However, when Patient #11 was asked to release the belt, the patient was unable to do so. Subsequent to surveyor inquiry, staff identified the waist belt met the criteria for a restraint and obtained a practitioner's order for the restraint. Review of the patient's care plan failed to identify the patient's need for a waist belt.

l. In addition, Patient #11's profile (care card that staff reference to identify care the patient required) was not updated to identify the patient's current restraint needs.



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Based on medical record reviews, review of hospital policies and interviews for one of two patients who required thickened liquids (Patient #3), for three of four patients (Patients #3, #4, #6, #7) who required staff assistance for activities of daily living (ADL) and/or for and/or for three of four patients identified as a nutritional risk (Patients #4, #6, #7), the hospital failed to follow and/or revise the patient's plan of care. The findings include:

a Patient #3 was admitted to the acute psychiatric unit on12/24/09 with diagnoses that included dementia, dysphagia and a history of aspiration pneumonia. Physician orders dated 12/24/09 directed nectar thickened liquids. The patient ' s plan of care dated 12/24/09 and patient profile (utilized by nurse aides) also identified nectar-thickened liquids. Observation on 12/29/09 at 10:35 AM noted that NA #1 placed an ice cube in a cup of water after the water had been thickened to a honey consistency and gave it to Patient #3. As Patient #3 drank the liquid, the ice cube melted and after five minutes the patient coughed three times, finished the drink and placed the remainder of the ice cube in his/her mouth. Interview with RN #1 on 12/29/09 at 11:35 AM indicated that an ice cube could be used to cool liquids but needed to fully melt before thickener was added to reach the desired consistency. Although the policy for standards of care for dysphagia did not include the amount of commercial thickener needed to achieve a desired consistency, directions were located on the commercial thickener container and did not direct adding an ice cube to the liquid after the liquid was thickened.

b. Patient #3's diagnoses included dementia. Physician orders dated 12/24/09 directed to ambulate with assistance. The patient's profile identified ambulation as desired with assistance. Nurse aide flow records from 12/24/09 to 12/29/09 noted that ambulation "did not occur". Intermittent observations of Patient #3 on 12/29/09 from 10:15 AM to 2:25 PM noted Patient #3 in a wheelchair in the Day Room. Interview with NA #2 on 12/29/09 at 10:15 AM indicated that he/she had never observed Patient #3 walking. Interview with the Assistant Director of Nursing 12/29/09 at 10:56 AM identified that patient ' s are ambulated once on the dayshift and once on the evening shift by nursing staff.

c. Patient #6 was admitted from an acute general hospital on 12/15/09 with diagnoses of dementia with behavioral disturbances and dysphagia. The interagency referral report dated 12/15/09 directed activity as tolerated with rolling walker and assistance and Physical Therapy (PT) evaluation if available. The assessment dated 12/15/09 identified that the patient required maximum assistance for ambulation and bathing and moderate assistance for feeding. Physician orders dated 12/15/09 directed, in part, full weight bearing and lacked a physician's order for a PT evaluation. The Occupational Therapy (OT) Assessments dated 12/17/09 indicated that the patient ' s standing and functional mobility were impaired yet the need for a PT evaluation was not addressed/ordered/recommended. The care plan dated 12/17/09 noted to ambulate with the assistance of 1-2 staff. The patient profile identified to ambulate with the assistance of one with a rolling walker. The nurse aide flow records from 12/17/09 to 12/28/09 noted that ambulation "did not occur". Observation on 12/29/09 at 2:27 PM noted that the patient was hesitant with shuffling gait when transferred with the assistance of 2 staff from the chair to the bed with the use of a gait belt and without the assistance of a rolling walker. Interview with NA #1 on 12/29/09 at 9:55 AM and/or 2:27 AM indicated that the patient ambulated with assistance from the bed to the bathroom and back earlier in the morning and ambulated "better" than at 2:27 PM. Interview with the Vice President of Nursing on 12/31/09 at 12 PM indicated that the practice on the psychiatric unit was to ambulate patients from their rooms to the Day Room in the morning time. Interview with the OT on 12/30/09 identified that OT assessed every new admission to include ambulation status, made recommendations according to the assessment and PT was available and required a physician's order.

The facility policy for ambulation identified that patients who could ambulate should be encouraged to ambulate on a daily basis with the appropriate assistance and assistive devices.

d. Patient #6 had diagnoses of dementia with behavioral disturbances and dysphagia. The assessment dated 12/15/09 indicated that the patient required maximum assistance for grooming and hygiene. The care plan dated 12/17/09 directed to provide assistance with ADL with the assistance of 1-2 staff as needed. Observation of the patient on 12/29/09 at 9:55 AM and 2PM noted that the patient had facial hair growth and was not clean-shaven. Interview with NA #3 on 12/29/09 at 2:20 PM identified that morning care included shaving male patients. Interview with NA #1 on 12/29/09 at 2:45 PM noted that the patient was provided morning care by the prior shift, he/she provided care to patients as needed and did not ask Patient #6 if the patient wished to be shaved.

e. Patient #6 was admitted on 12/15/09 and had diagnoses of dementia with behavioral disturbances and 2 Stage II pressure ulcers to the spine. The assessment dated 12/15/09 indicated that the patient was at low risk for pressure ulcer development and skin was fragile. The undated patient profile identified that the patient was incontinent of bowel and bladder at times. An assessment dated 12/16/09 indicated that the patient had a red rash to the buttock area and Critic Aid antifungal (AF) cream was ordered daily and as needed. An assessment dated 12/17/09 noted a 2centimeter (cm) by 0.5cm by 0.1 cm Stage II pressure ulcer to the gluteal fold and lacked documentation location (left or right). Nursing narratives noted that the physician was notified and there were no new orders. The assessment dated 12/23/09 at 11:56 PM identified a 1cm by 1cm Stage II pressure ulcer to the right buttock (gluteal fold) and a 0.4cm by 1cm Stage II pressure ulcer to the coccyx. The record lacked documentation that the physician was made aware of the coccyx pressure ulcer or that the treatment had been revised after the second pressure ulcer had developed (1/23/09 to 1/28/09). The treatment record from 12/16/09 to 12/28/09 indicated that the treatment of Critic Aid AF cream was applied as ordered to the patient ' s buttocks/coccyx/gluteal areas. Observation on 12/29/09 noted that the patient had Stage II pressure ulcers to the coccyx and right gluteal fold and exudates from or dressings to the ulcers were not observed. Interview with the Wound Nurse (ADON) on 12/29/09 at 1:50 PM indicated that Critic Aid was a skin barrier only and Critic Aid AF cream was used to treat fungal infections and dermatitis associated with incontinent patients. Although the hospital policy for pressure ulcer prevention identified that Critic Aid may be applied to denuded tissue, the policy did not include the use of Critic Aid AF as treatment for pressure ulcers. Product information noted that Critic Aid AF was used to treat skin infections such as athlete's foot, jock itch, ringworm, tinea versicolor, and yeast infections. Subsequently, the PA was notified of the Stage II pressure ulcers to the patient ' s bottom and a hydrophilic wound dressing (Triad) was ordered to these areas as well as Critic Aid AF to redness on buttocks.
In addition, physician orders dated 12/29/09 directed Triad to the Stage II sacral and right buttock ulcers daily and as needed. Observation of the treatment application on 12/29/09 at 2:55 PM noted that RN #2 applied the Triad hydrophilic wound dressing from the tube to the sacral and right buttock ulcers and a secondary dressing was not applied. Interview with the Wound Nurse on 12/29/09 at 2:50 PM indicated that a secondary dressing was not necessary when using Triad because Triad was an occlusive dressing. The hospital policy for pressure ulcer prevention identified treatment with Triad paste for Stage II pressure ulcers with moderate to large exudate. Product information for Triad directed to apply a thin layer and cover with a secondary dressing for low exudating wounds.
In addition, on 12/30/09 at approximately 2PM, RN #3 was asked by this Surveyor to view treatments for Patient #6. On 12/30/09 at 2:27 PM and upon this Surveyor's return to the unit, interview with RN #3 indicated that he/she had just completed Patient #6's treatment. Interview with RN #3 at this time noted that he/she had just applied a Biatin (foam) dressing to the patient's coccyx and Triad (hydroliphic) to the patient's right buttock. RN #3 responded "He has an area on his back?" when queried about what dressing was applied to the patient's spine. Review of the computerized record with RN #3 was conducted on 12/30/09 between 2:27 PM and 2:30 PM at which time RN #3 noted again that he/she had applied Biatin to the patient's coccyx. Although RN #3 on 12/30/09 later denied that he/she had administered treatments incorrectly to Patient #6, RN #3 was observed on 12/30/09 at 2:30 PM (immediately after reviewing the computerized record) to reenter Patient #6's room with a Biatin dressing and the Triad tube.

f. Patient #6 had diagnoses of dementia with behavioral disturbances and dysphagia. The assessment and/or weight record dated 12/15/09 indicated that the patient required moderate assistance for feeding and weighed 134.2 pounds. The undated patient profile indicated "set- up" for feeding ability. Physician orders dated 12/15/09 and12/16/09 directed, in part, a mechanical soft, ground diet and weekly weight. The nutritional risk assessment dated 12/16/09 noted that the patient was a high nutritional risk, had a history of weight loss or inadequate intake, recommended a nutritional supplement (Promod three times a day (TID) and to follow- up as needed. The assessment also identified that the patient had a Stage II pressure ulcer and nutritional goals to maintain weight and intake of greater than 50% of meal trays. The plan of care dated 12/16/09 noted an approach to consult dietary as needed. Meal intake records from 12/16/09 to 12/20/09 indicated that the patient consumed half or less than 50% of the meal on 12 of 13 occasions. Medication administration records (MAR) from 12/17/09 to 12/21/09 directed to record the amount of Promod consumed TID and identified that the patient refused the Promod on 5 of 15 occasions and the amount of Promod taken by the patient was not recorded for 6 of 10 occasions. Weight records identified that on 12/20/09 the patient had lost 6.7 pounds in 5 days. The record lacked documentation for dietary follow- up or that the plan of care was revised when the patient failed to meet dietary goals and had a weight loss. Interview with the Dietician on 1/6/10 at 9:55 AM noted that he/she would expect to be notified if a patient were not eating well, or not taking a recommended supplement and that a change in supplement could be tried. Interview with the Dietician on 1/12/09 at 1:35 PM identified that the hospital did not have a policy directing approaches and monitoring for each nutritional risk level. The hospital policy for nutritional assessments identified that a dietician will complete weekly monitoring of patients identified at nutritional risk. The policy also indicated that patients who had a Stage II pressure ulcer or greater will be nutritionally assessed and recommendations for changes in dietary orders to include changes in content, consistency, and supplementation as needed would be provided.
In addition, review Patient #6's record on 12/30/09 with the Nurse Education Specialist identified that although the physician had ordered weekly weights to be done, the patient had not been reweighed after 12/20/09 (10 days).

In addition, Physician orders for Patient #6 dated 12/16/09 directed to encourage a minimum of 1500milliliters (ml) of fluids per day and monitor intake and output. The nutritional risk assessment dated 12/16/09 noted that the patient required 1830 ml/day and usually consumed 1000 to 1499 ml/day. Fluid intake records from 12/16/09 to 12/21/09 identified that the patient did not meet fluid intake goals and took less than 959 ml of fluids per 24 hour period from 12/17/09 to 12/21/09. The medical record lacked documentation that the patient's plan of care was revised from 12/17/09 to 12/20/09 when the patient ' s fluid needs were not met. Medical progress notes dated 12/21/09 indicated that the Physician's Assistant was aware of the patient's decreased fluid intake; blood work completed on 12/21/09 indicated that the patient was dehydrated and IV fluids were ordered and administered. The policy for intake and output (I/O) identified that the night nurse will relay I/O information to the day nurse to communicate to the practitioner as needed. The day shift nurse will review the prior 24-hour of I/O, review the need for changes in the plan of care with the practitioner as necessary and document in the medical record the need for changes in the plan of care with the practitioner as necessary and document in the medical record.

g. Patient #7 had diagnoses of dementia with behavioral disturbances. The assessment dated 1/3/09 identified that the patient was lethargic. The patient profile (undated) indicated that the patient required the assistance of 1 staff for hygiene. Nursing flow sheets dated 1/3/09 (Saturday) at 5:27 AM indicated that the patient had a shower with the assistance of 2 staff. The care plan dated 1/5/09 directed the assistance of staff for activities of daily living. Nursing narratives and/or nurse aide flow records from 1/4/09 to 1/13/09 lacked documentation that Patient #1 received a shower or shave to include the scheduled shower day of Saturday, 1/10/09. Interview with the Nursing Director of Psychiatric Services on 12/29/09 at 11:20 AM noted that a weekly shower schedule was in place and a patient would also receive a shower when soiled or per request. The Nursing Staff Assignment for showers and weights indicated that shower days were assigned according to the patient's room location and Patient #7 was scheduled for Saturday showers. The hospital patient care policy directed that bed baths would be done by nursing when needed in between showers or tub baths and lacked documentation for the routine frequency of showering/tub baths.

h. Patient #4 was admitted on 12/11/09 with a diagnosis of dementia with behavioral disturbances. Physician orders dated 12/11/09 directed weekly weights and regular diet. The undated patient profile identified that the patient was independent for eating. Weight records indicated that the patient weighed 130.1 pounds on 12/11/09. The initial nutritional risk assessment dated 12/14/09 noted that the patient was a high nutritional risk, ideal body weight range was 88-108 pounds and had poor intake (food and fluids). The assessment also identified the patient was a high nutritional risk, goals included to maintain weight and an approach that dietician will remain available and follow- up as needed. Physician orders dated 12/14/09 directed a 2.0-calorie house supplement TID. The Medication Administration Record (MAR) from 12/14/09 to 12/28/09 identified that the patient refused the supplement, or consumed only 25% of the supplement on 26 of 37 occasions. Flow sheets from 12/14/09 to 12/27/09 noted that the patient refused meals on 15 occasions. Weight records indicated that the patient was reweighed 17 days later (instead of weekly) on 12/28/09, weighed 124.7 pounds and had lost 5.4 pounds. Review of the patient's computerized record with the Nurse Education Specialist on 12/30/09 noted that subsequent assessments by the dietician were not documented and the patient's plan of care for food/supplement intake had not been revised after 12/14/09. The hospital policy for nutritional assessments identified that a dietician will complete weekly monitoring of patients identified at nutritional risk.
In addition, Patient #4's plan of care dated 12/14/09 directed to record the amount of food intake. Review of the patient ' s meal intake records with the Nurse Education Specialist on 12/30/09 noted that 6 out of 15 supper meals were not recorded from 12/15/09 to 12/29/09 and for the breakfast and lunch meals on 12/22/09.

i. Patient #7 had diagnoses of dementia with behavioral disturbances. The assessment dated 1/3/09 identified that the patient was lethargic. Physician orders dated 1/3/09 directed a regular, cut textured diet and weekly weights. The initial nutritional assessment dated 1/3/09 identified that the patient was a high nutritional risk and weight was estimated to be 190 pounds, as the admission weight had not yet been obtained. The plan of care dated 1/3/09 indicated to record the amount of meal intake. The computerized weight record was reviewed with the Nurse Education Specialist on 12/31/09 and per interview and review identified that the patient's weight was never obtained throughout the patient's hospital stay (1/3/09 through 1/14/09).

Based on clinical record review, and interview with staff for 1 patient (Patient #9), who utilized oxygen with a range of concentrations, the hospital failed to ensure that the specific concentration of oxygen the patient received was consistently documented. The findings include:

a. Patient #9 was admitted with diagnoses that included pulmonary fibrosis. A practitioner's order dated 1/27/09 identified that the patient was to receive oxygen between 1-5 liters per minute by nasal canula to maintain oxygen saturation rates at or above 90%. The clinical record was reviewed with the Director of Nursing on 12/31/09 at 10 AM and identified that between 12/28/09 and 12/31/09, the vital signs sheet, treatment/medication sheets, and progress notes failed to consistently identify the amount of oxygen the patient received. The Director of Nursing identified that the hospital did not have a policy or protocol to address how much oxygen to administer or how to document the amount of oxygen administered, per range orders.




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Based on medical record review, review of hospital policies/bylaws and interview, for three of thirteen patients (Patients #4, #6, #7) on the Geriatric Medical/Psychiatric Program (GMPP) unit the hospital failed to maintain accurate and/or complete records. The findings include:

Patients # 4 and #7 electronic records were reviewed with the Nurse Education Specialist on 12/30/09and/or 12/31/09 and per the review and interview with the Nurse Education Specialist at this time, multiple patient record inaccuracies or incomplete patient records were noted.

a. Patient #7 was admitted to the psychiatric unit on 1/ 3/09 with a diagnosis of dementia with behavioral disturbances. Physician orders dated 1/3/09 directed to ambulate as desired with assistance. Nurse aide flow records dated 1/4/09 documented that ambulation did not occur on all three shifts although documentation also identified that the number of feet that the patient ambulated was 10 or 20 feet on each shift. Nurse aide flow records dated 1/8/09 indicated that the patient ambulated 50 feet on the day and evening shifts and nursing narratives also documented that the patient ambulated the length of the hall several times on the day shift and ambulated a long time on the evening shift.
In addition, the nurse aide flow records indicated that the patient did not ambulate with nursing staff on for three shifts on 1/6/09 and 1/7/09 and the record lacked documentation as to why the patient did not ambulate with nursing staff.

b. Patient #7 had diagnoses of dementia with behavioral disturbances. The assessment dated 1/3/09 identified that the patient was lethargic. Physician orders dated 1/3/09 directed a regular, cut textured diet and weekly weights. The plan of care dated 1/3/09 indicated to record the amount of meal intake. Physician orders dated 1/6/09 directed that patient needs to be fed. Computerized flow/weight records and nursing documentation was reviewed with the Nurse Education Specialist on 12/31/09. The review and interview with the Nurse Education Specialist on 12/31/09 identified that the patient's meal intakes were not recorded on 1/8/09 and 1/14/09 for the breakfast and lunch meals and the supper meal on 1/5/09. Flow records and nursing narratives documented conflicting meal intakes and/or the level of feeding assistance provided.
In addition, Patient #7's record failed to reflect the patient's weight when the patient was hospitalized from 1/3/09 to 1/14/09.
In addition, a physician's order for Patient #7 dated 1/9/09 directed to cleanse eyelids twice a day with baby shampoo. The treatment record lacked documentation that the patient's eyelids were cleansed on the evening shift on 1/12/09 and 1/13/09 and the day shift on 1/14/09 (Patient discharged at 4:30 PM on 1/13/09).
In addition, flow sheets for Patient #7 identified that the patient had a bed bath on 1/13/09 and the Primary Therapist note dated 1/13/09 noted that the patient was showered and shaved.
In addition Patient #7's physician orders dated 1/3/09 directed to ambulate as desired with assistance. Although flow sheets dated 1/4/09 for the night, day and evening shifts identified that the patient ambulated 10 or 20 feet, the flow sheets identified that ambulation did not occur on each shift.

c. Patient #4's plan of care dated 12/14/09 directed to record the amount of food intake. Review of the patient 's meal intake records with the Nurse Education Specialist on 12/30/09 noted that 6 out of 15 supper meals were not recorded from 12/15/09 to 12/29/09 and for the breakfast and lunch meals on 12/22/09.

d. Patient #6 was admitted on 12/15/09 and had diagnoses of dementia with behavioral disturbances and 2 Stage II pressure ulcers to the spine. An assessment dated 12/17/09 noted a 2 centimeter (cm) by 0.5cm by 0.1 cm Stage II pressure ulcer to the gluteal fold and lacked documentation for left or right. The assessment dated 12/23/09 at 11:56 PM identified a 1cm by 1cm Stage II pressure ulcer to the right buttock (gluteal fold) and a 0.4cm by 1cm Stage II pressure ulcer to the coccyx and conflictingly indicated that the ulcer to the coccyx had been originally identified on 12/17/09.
In addition, the wound assessment dated 12/30/09 conflictingly documented that the initial date of occurrence for the sacral and right buttock pressure ulcers was 12/24/09.

The hospital staff rules and regulations identified that the patient's record content shall be pertinent and accurate.










19826

Based on review of the clinical record, interview and review of policy and procedure, for one patient (Patient #19) that received blood, the hospital failed to ensure that the documentation for the administration of blood was complete. The findings include:

a. Patient #19 was admitted to the hospital on 12/16/09 with the diagnosis of bilobar aspiration pneumonia and a medical history that included dementia with behavioral disturbances, coronary artery disease and atrial fibrillation. Review of the clinical record dated 12/19/09 at 5:30 P.M. and 11:30 P.M. identified that a unit of blood was started and documentation on the transfusion tag was not complete-including that prior to the transfusion two staff members established the identity of the patient, that the blood type of the unit number on the tag agree with the unit number on the blood, the amount of blood given when the transfusion was ended, who ended the transfusion and if the patient experienced a reaction to the transfusion. Interview with Nurse Manager #1 on 12/31/09 identified that the transfusion documentation was not complete. Review of the hospital policy and procedure, titled " Blood and Blood Component Administration " , identified that documentation includes that two Registered Nurses establish the identity of the patient, match the unit number to the number on the blood product, and after the transfusion documentation includes the amount of blood administered, the name and title of the person that ended the transfusion and if the patient experienced a transfusion reaction.

Based on observation, interview and review of hospital policies and procedures for one unit (the Acute Care Unit (ACU) that had patient medications present, the hospital failed to ensure that the medications were secured. The findings include:

a. During a tour of the ACU on 12/29/09 with Nurse Manager #2, it was identified that a medication cart, not in use and/or attended by a nurse, was stored in and unsecured area and/or the cart was not locked. Interview with RN #21 on 12/29/09 identified that the storage area and the cart should be locked. Review of the hospital policy and procedure, titled "Medication Ordering, Scheduling and Administration " , identified that when medication carts are not in use the cart must be stored in a secured area and the cart is locked when a nurse is not in attendance of the cart. In addition, observation in the medication room identified that the refrigerated narcotic medications were not double locked. Review of the policy and procedure, titled "Controlled Drugs " , identified that all controlled medications are kept under double lock.

Based on observation and interview with staff, one food service employee failed to follow established infection control practices while preparing food. The findings include:

a. A tour of the dietary department was conducted on 12/30/09 at 11:15 AM with the Food Service Director. Dietary Aide #1 was observed preparing food with hair protruding several inches beyond the hair net. The Food Service Director identified that the employee should not have had his/her hair outside of the hair net.

Based on a tour of the hospital and staff interview, the facility failed to ensure that the psychiatric unit was maintained in such a manner as to promote the safety and well being of patients.

a. On 12/29/09 at 09:00 AM and various times throughout the day, while touring the adult psychiatric units on Stugis 4 with the Director of Materials Management & Environmental Services the following was observed:

b. The faucet and shower controls, sprinkler heads, door handles, door hinges, wardrobe hanger rails, and privacy curtains between beds posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard. Subsequent interview of the Director of Environmental Services indicated that a current risk based analysis by the facility prior to this inspection had not been completed.

c. On 12/29/09 at 10:45 AM and various times throughout the day, while touring the adult psychiatric units on Stugis 4 with the Director of Materials Management & Environmental Services the following was observed:

d. The wardrobe units in patient rooms were found to be unlocked and interview of the staff nurse for the Stugis 4 Unit indicated that the wardrobe units were normally locked and could not explain why they were unlocked for the 6 patient rooms toured. Subsequent to surveyor observation and interview they were all found to be locked.








19826

Based on observations, interviews and review of the hospital policy and procedure for one unit (the Acute Care Unit (ACU)) that had three refrigerator and freezers for patient use, the hospital failed to ensure that the temperatures were monitored and/or that temperatures not meeting the acceptable range were reported and/or addressed. The findings include:

a. During a tour of the ACU on 12/29/09 with Nurse Manager #2, it was identified that the medication freezer temperature for December 2009 had not been documented and/or monitored. The freezer temperatures in the hospice lounge were outside the range and were not reported and/or addressed. Review of a preventative maintenance record for the three refrigerator/freezers on ACU dated 12/18/09 identified that the maintenance staff completed the preventative maintenance on the two freezers including checking temperatures. Interview with the Director of Maintenance and the Manager of Maintenance on 12/31/09 identified that if the refrigerator and/or freezer temperatures were not in the acceptable range, the staff would call maintenance. The maintenance staff would address the issue and the preventative maintenance completed on 12/18/09 identified that all of the refrigerators and freezers were in working order. Review of the policy and procedure, titled "Refrigerator Temperatures in Patient/Resident Care Areas , identified that the refrigerator freezers temperatures are monitored daily, the acceptable freezer temperature range is 0 degrees Fahrenheit or less and temperatures not in the accepted range are reported immediately.

Based on a tour of the psychiatric hospital, medical record review, observations and interviews, the hospital failed to maintain a safe environment. The findings include:

a. Patient #8's record identified that he/she was admitted on 12/16/09 for increasing anxiety and depression. Physician orders dated 12/16/09 included nebulizer treatments as needed. The plan of care dated 12/17/09 noted an approach to maintain a safe environment. The treatment record identified that the patient had not received a nebulizer treatment after 12/24/09. A tour of the psychiatric medical unit was conducted on 12/29/09. Ambulatory patients were observed on the unit as well as a nebulizer machine with an unplugged cord in the room of Patient #8 at 9:30 AM. Interview with the Vice President of Nursing on 12/29/09 at 9:30 AM identified that the nebulizer machine was not kept in patient rooms. Interview with RN #4 at this time noted that the patient had not yet received a nebulizer treatment on the day shift. Subsequently, the nebulizer machine was removed from the patient's room.

b. A tour of the psychiatric medical unit on 12/29/09 at 10 AM identified that food and fluids were stored in the nourishment station. The lock on the door was in the locked position, and the door was left opened. Patients were observed ambulating on the unit or mobile in wheelchairs at this time. Interview with the Assistant Director of Nursing (ADON) at 10 AM on 12/29/09 noted that the nourishment room door should be locked and closed. Subsequently the nourishment room door was pushed closed by the ADON and would require a key to be reopened.

Based on medical record reviews, review of hospital policies, observations and interviews for one of one patient observed during treatment of the pressure ulcers (Patient #6), the nurse failed to follow accepted infection prevention practices. The findings include:

a. Patient #6 was admitted on 12/15/09 and had diagnoses of dementia with behavioral disturbances and 2 Stage II pressure ulcers to the spine. The assessment dated 12/23/09 at 11:56 PM identified a 1cm by 1cm Stage II pressure ulcer to the right buttock (gluteal fold) and a 0.4cm by 1cm Stage II pressure ulcer to the coccyx. Physician orders dated 12/29/09 directed Triad the Stage II sacral and right buttock ulcers daily and as needed. Observation of the treatment application on 12/29/09 at 2:55 PM noted that RN #2 donned gloves, sprayed the patient's entire buttocks with wound cleanser and dried the patient ' s buttocks around the 2 ulcers using 4x4 gauze. RN #2 then opened the Triad tube and with the same gloves and using the right index finger, applied the Triad hydrophilic wound dressing to the sacral and right buttock ulcers. Observation also indicated that the Triad tube was stored at the nursing station in the unit treatment cart. Interview with the Infection Control Nurse (ADON) on 12/29/09 at 3PM noted that RN #2 should have used separate cotton- tipped applicators to apply the Triad to each wound separately. The hospital policy for clean dressing technique identified after wound cleansing, remove gloves, wash hands, apply clean gloves, apply any medication ordered and dress the wound.





19826

Based on observation, interviews and review of hospital policy and procedure for three of four patients (Patient #15, #16 and #17) that were deceased, the hospital failed to ensure that the patient ' s personal property was stored and/or disposed of according to policy and procedure. The findings include:

a. During a tour of the Acute Care Unit (ACU) on 12/29/09 and 12/30/09 it was observed that the personal belongings of Patients #15, #16 and #17, including clothing, footwear and medications were stored in the linen room. Interview with Nurse Manager #2 on 12/29/09 and the Infection Control Practitioner on 12/30/09 identified that the linen room is not the place to store patient personal property. Interview with Social Worker #1, on 12/31/09, identified that he/she was not aware of any personal property of deceased patients that needed to be stored and/or disposed of from the ACU. Review of the hospital policy and procedure, titled " Disposition of Deceased Resident ' s Personal Property " , identified that after a patient has died, their belongings are packed by either nursing or environmental services, the property is stored in Cage 3A and a letter is sent to the patient ' s family member/significant other to claim the property.

Based on medical record reviews, review of hospital policies and interviews for one of four patients who were admitted to the acute psychiatric hospital and reviewed for Occupational Services (Patient #7), the hospital failed to provide therapy assessments in accordance with facility policy. The findings include:

a. Patient #7 was admitted to the acute psychiatric unit on Saturday 1/3/09 at 2:47 AM with diagnoses of dementia with behavioral disturbances. The Occupational Therapy (OT) note dated 1/5/09 at 4:17 PM identified that the OT evaluation was initiated.
Patient #6 was admitted to the acute psychiatric unit on Tuesday 12/15/09 at approximately 7 PM with diagnoses of dementia with behavioral disturbances. The initial OT evaluation was dated 12/17/09 at 5:15 PM. Interview with the Occupational Therapist on 12/30/09 at 1 PM noted that the OT department was available Monday through Friday from 7:30 to 4:30 PM. The OT further indicated that if a patient was admitted after 4:30 PM on a Friday, the patient would be evaluated the following Monday. The hospital policy for in- patient assessments identified that the initial screening process for functional and rehabilitation status, including OT, will be done by the therapist within 24 hours in acute care and sub- acute rehabilitation and within 3 working days in long- term care.